|
FLUDROCORTISONE 0.1 MG ORAL TAB
|
Facility
|
IP
|
$2.99
|
|
|
Service Code
|
NDC 50268033015
|
| Hospital Charge Code |
10054
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$2.78 |
| Rate for Payer: Aetna Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna All Commercial |
$2.58
|
| Rate for Payer: CORVEL All Commercial |
$2.78
|
| Rate for Payer: Coventry All Commercial |
$2.63
|
| Rate for Payer: Encore All Commercial |
$2.75
|
| Rate for Payer: Frontpath All Commercial |
$2.75
|
| Rate for Payer: Humana ChoiceCare |
$2.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.69
|
| Rate for Payer: PHCS All Commercial |
$2.24
|
| Rate for Payer: PHP All Commercial |
$2.27
|
| Rate for Payer: Sagamore Health Network All Products |
$2.31
|
| Rate for Payer: Signature Care EPO |
$2.48
|
| Rate for Payer: Signature Care PPO |
$2.63
|
| Rate for Payer: United Healthcare Commercial |
$2.36
|
|
|
FLUMAZENIL 0.1 MG/ML IV SOLN
|
Facility
|
IP
|
$30.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.63 |
| Max. Negotiated Rate |
$28.06 |
| Rate for Payer: Aetna Commercial |
$26.07
|
| Rate for Payer: Cash Price |
$18.10
|
| Rate for Payer: Cigna All Commercial |
$26.04
|
| Rate for Payer: CORVEL All Commercial |
$28.06
|
| Rate for Payer: Coventry All Commercial |
$26.55
|
| Rate for Payer: Encore All Commercial |
$27.77
|
| Rate for Payer: Frontpath All Commercial |
$27.76
|
| Rate for Payer: Humana ChoiceCare |
$26.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.15
|
| Rate for Payer: PHCS All Commercial |
$22.63
|
| Rate for Payer: PHP All Commercial |
$22.88
|
| Rate for Payer: Sagamore Health Network All Products |
$23.29
|
| Rate for Payer: Signature Care EPO |
$25.04
|
| Rate for Payer: Signature Care PPO |
$26.55
|
| Rate for Payer: United Healthcare Commercial |
$23.77
|
|
|
FLUMAZENIL 0.1 MG/ML IV SOLN
|
Facility
|
OP
|
$30.17
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$28.06 |
| Rate for Payer: Aetna Commercial |
$25.46
|
| Rate for Payer: Aetna Medicare |
$9.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$17.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.62
|
| Rate for Payer: Cash Price |
$18.10
|
| Rate for Payer: Centivo All Commercial |
$16.41
|
| Rate for Payer: Cigna All Commercial |
$26.04
|
| Rate for Payer: CORVEL All Commercial |
$28.06
|
| Rate for Payer: Coventry All Commercial |
$26.55
|
| Rate for Payer: Encore All Commercial |
$27.77
|
| Rate for Payer: Frontpath All Commercial |
$27.76
|
| Rate for Payer: Humana ChoiceCare |
$26.06
|
| Rate for Payer: Humana Medicare |
$9.65
|
| Rate for Payer: Lucent All Commercial |
$16.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.15
|
| Rate for Payer: PHCS All Commercial |
$22.63
|
| Rate for Payer: PHP All Commercial |
$22.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.77
|
| Rate for Payer: Sagamore Health Network All Products |
$23.29
|
| Rate for Payer: Signature Care EPO |
$25.04
|
| Rate for Payer: Signature Care PPO |
$26.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25.64
|
| Rate for Payer: United Healthcare Commercial |
$23.77
|
| Rate for Payer: United Healthcare Medicare |
$9.65
|
|
|
FLUORESCEIN 1 MG OPHT STRP
|
Facility
|
OP
|
$1.79
|
|
|
Service Code
|
NDC 17238090011
|
| Hospital Charge Code |
27663
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$1.51
|
| Rate for Payer: Aetna Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.12
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.63
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Centivo All Commercial |
$0.97
|
| Rate for Payer: Cigna All Commercial |
$1.55
|
| Rate for Payer: CORVEL All Commercial |
$1.67
|
| Rate for Payer: Coventry All Commercial |
$1.58
|
| Rate for Payer: Encore All Commercial |
$1.65
|
| Rate for Payer: Frontpath All Commercial |
$1.65
|
| Rate for Payer: Humana ChoiceCare |
$1.55
|
| Rate for Payer: Humana Medicare |
$0.57
|
| Rate for Payer: Lucent All Commercial |
$0.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.61
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$1.34
|
| Rate for Payer: PHP All Commercial |
$1.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.70
|
| Rate for Payer: Sagamore Health Network All Products |
$1.38
|
| Rate for Payer: Signature Care EPO |
$1.49
|
| Rate for Payer: Signature Care PPO |
$1.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.52
|
| Rate for Payer: United Healthcare Commercial |
$1.41
|
| Rate for Payer: United Healthcare Medicare |
$0.57
|
|
|
FLUORESCEIN 1 MG OPHT STRP
|
Facility
|
IP
|
$1.79
|
|
|
Service Code
|
NDC 17238090011
|
| Hospital Charge Code |
27663
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Aetna Commercial |
$1.55
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna All Commercial |
$1.55
|
| Rate for Payer: CORVEL All Commercial |
$1.67
|
| Rate for Payer: Coventry All Commercial |
$1.58
|
| Rate for Payer: Encore All Commercial |
$1.65
|
| Rate for Payer: Frontpath All Commercial |
$1.65
|
| Rate for Payer: Humana ChoiceCare |
$1.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.61
|
| Rate for Payer: PHCS All Commercial |
$1.34
|
| Rate for Payer: PHP All Commercial |
$1.36
|
| Rate for Payer: Sagamore Health Network All Products |
$1.38
|
| Rate for Payer: Signature Care EPO |
$1.49
|
| Rate for Payer: Signature Care PPO |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$1.41
|
|
|
FLUOROESTRADIOL F-18 148 MBQ/ML TO 3,700 MBQ/ML IV SOLN
|
Facility
|
IP
|
$15,885.87
|
|
|
Service Code
|
HCPCS A9591
|
| Hospital Charge Code |
192951
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$11,914.40 |
| Max. Negotiated Rate |
$14,773.86 |
| Rate for Payer: Aetna Commercial |
$13,725.39
|
| Rate for Payer: Cash Price |
$9,531.52
|
| Rate for Payer: Cigna All Commercial |
$13,709.51
|
| Rate for Payer: CORVEL All Commercial |
$14,773.86
|
| Rate for Payer: Coventry All Commercial |
$13,979.57
|
| Rate for Payer: Encore All Commercial |
$14,622.94
|
| Rate for Payer: Frontpath All Commercial |
$14,615.00
|
| Rate for Payer: Humana ChoiceCare |
$13,720.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,297.28
|
| Rate for Payer: PHCS All Commercial |
$11,914.40
|
| Rate for Payer: PHP All Commercial |
$12,047.84
|
| Rate for Payer: Sagamore Health Network All Products |
$12,263.89
|
| Rate for Payer: Signature Care EPO |
$13,185.27
|
| Rate for Payer: Signature Care PPO |
$13,979.57
|
| Rate for Payer: United Healthcare Commercial |
$12,518.07
|
|
|
FLUOROESTRADIOL F-18 148 MBQ/ML TO 3,700 MBQ/ML IV SOLN
|
Facility
|
OP
|
$15,885.87
|
|
|
Service Code
|
HCPCS A9591
|
| Hospital Charge Code |
192951
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$4,924.62 |
| Max. Negotiated Rate |
$14,773.86 |
| Rate for Payer: Aetna Commercial |
$13,407.67
|
| Rate for Payer: Aetna Medicare |
$5,083.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4,924.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$9,123.26
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9,930.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5,846.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5,591.83
|
| Rate for Payer: Cash Price |
$9,531.52
|
| Rate for Payer: Centivo All Commercial |
$8,641.91
|
| Rate for Payer: Cigna All Commercial |
$13,709.51
|
| Rate for Payer: CORVEL All Commercial |
$14,773.86
|
| Rate for Payer: Coventry All Commercial |
$13,979.57
|
| Rate for Payer: Encore All Commercial |
$14,622.94
|
| Rate for Payer: Frontpath All Commercial |
$14,615.00
|
| Rate for Payer: Humana ChoiceCare |
$13,720.63
|
| Rate for Payer: Humana Medicare |
$5,083.48
|
| Rate for Payer: Lucent All Commercial |
$8,641.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,297.28
|
| Rate for Payer: PHCS All Commercial |
$11,914.40
|
| Rate for Payer: PHP All Commercial |
$12,047.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,195.49
|
| Rate for Payer: Sagamore Health Network All Products |
$12,263.89
|
| Rate for Payer: Signature Care EPO |
$13,185.27
|
| Rate for Payer: Signature Care PPO |
$13,979.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,502.99
|
| Rate for Payer: United Healthcare Commercial |
$12,518.07
|
| Rate for Payer: United Healthcare Medicare |
$5,083.48
|
|
|
FLUOROMETHOLONE 0.25 % OPHT DRPS
|
Facility
|
IP
|
$347.36
|
|
|
Service Code
|
NDC 11980022805
|
| Hospital Charge Code |
19722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$260.52 |
| Max. Negotiated Rate |
$323.04 |
| Rate for Payer: Aetna Commercial |
$300.12
|
| Rate for Payer: Cash Price |
$208.41
|
| Rate for Payer: Cigna All Commercial |
$299.77
|
| Rate for Payer: CORVEL All Commercial |
$323.04
|
| Rate for Payer: Coventry All Commercial |
$305.68
|
| Rate for Payer: Encore All Commercial |
$319.74
|
| Rate for Payer: Frontpath All Commercial |
$319.57
|
| Rate for Payer: Humana ChoiceCare |
$300.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$312.62
|
| Rate for Payer: PHCS All Commercial |
$260.52
|
| Rate for Payer: PHP All Commercial |
$263.44
|
| Rate for Payer: Sagamore Health Network All Products |
$268.16
|
| Rate for Payer: Signature Care EPO |
$288.31
|
| Rate for Payer: Signature Care PPO |
$305.68
|
| Rate for Payer: United Healthcare Commercial |
$273.72
|
|
|
FLUOROMETHOLONE 0.25 % OPHT DRPS
|
Facility
|
OP
|
$347.36
|
|
|
Service Code
|
NDC 11980022805
|
| Hospital Charge Code |
19722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$323.04 |
| Rate for Payer: Aetna Commercial |
$293.17
|
| Rate for Payer: Aetna Medicare |
$111.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$107.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$199.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$217.13
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$127.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$122.27
|
| Rate for Payer: Cash Price |
$208.41
|
| Rate for Payer: Cash Price |
$208.41
|
| Rate for Payer: Centivo All Commercial |
$188.96
|
| Rate for Payer: Cigna All Commercial |
$299.77
|
| Rate for Payer: CORVEL All Commercial |
$323.04
|
| Rate for Payer: Coventry All Commercial |
$305.68
|
| Rate for Payer: Encore All Commercial |
$319.74
|
| Rate for Payer: Frontpath All Commercial |
$319.57
|
| Rate for Payer: Humana ChoiceCare |
$300.01
|
| Rate for Payer: Humana Medicare |
$111.15
|
| Rate for Payer: Lucent All Commercial |
$188.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$312.62
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$260.52
|
| Rate for Payer: PHP All Commercial |
$263.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$135.47
|
| Rate for Payer: Sagamore Health Network All Products |
$268.16
|
| Rate for Payer: Signature Care EPO |
$288.31
|
| Rate for Payer: Signature Care PPO |
$305.68
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$295.25
|
| Rate for Payer: United Healthcare Commercial |
$273.72
|
| Rate for Payer: United Healthcare Medicare |
$111.15
|
|
|
FLUOXETINE 10 MG ORAL CAP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 65862019201
|
| Hospital Charge Code |
10069
|
|
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
|
|
|
FLUOXETINE 10 MG ORAL CAP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 65862019201
|
| Hospital Charge Code |
10069
|
|
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
|
|
|
FLUOXETINE 20 MG ORAL CAP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904734661
|
| Hospital Charge Code |
10070
|
|
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
|
|
|
FLUOXETINE 20 MG ORAL CAP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904734661
|
| Hospital Charge Code |
10070
|
|
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
|
|
|
FLUPHENAZINE HCL 5 MG ORAL TAB
|
Facility
|
OP
|
$30.94
|
|
|
Service Code
|
NDC 00527179001
|
| Hospital Charge Code |
3221
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.59 |
| Max. Negotiated Rate |
$28.77 |
| Rate for Payer: Aetna Commercial |
$26.11
|
| Rate for Payer: Aetna Medicare |
$9.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$17.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.34
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.89
|
| Rate for Payer: Cash Price |
$18.56
|
| Rate for Payer: Centivo All Commercial |
$16.83
|
| Rate for Payer: Cigna All Commercial |
$26.70
|
| Rate for Payer: CORVEL All Commercial |
$28.77
|
| Rate for Payer: Coventry All Commercial |
$27.23
|
| Rate for Payer: Encore All Commercial |
$28.48
|
| Rate for Payer: Frontpath All Commercial |
$28.46
|
| Rate for Payer: Humana ChoiceCare |
$26.72
|
| Rate for Payer: Humana Medicare |
$9.90
|
| Rate for Payer: Lucent All Commercial |
$16.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.85
|
| Rate for Payer: PHCS All Commercial |
$23.20
|
| Rate for Payer: PHP All Commercial |
$23.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.07
|
| Rate for Payer: Sagamore Health Network All Products |
$23.89
|
| Rate for Payer: Signature Care EPO |
$25.68
|
| Rate for Payer: Signature Care PPO |
$27.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.30
|
| Rate for Payer: United Healthcare Commercial |
$24.38
|
| Rate for Payer: United Healthcare Medicare |
$9.90
|
|
|
FLUPHENAZINE HCL 5 MG ORAL TAB
|
Facility
|
IP
|
$30.94
|
|
|
Service Code
|
NDC 00527179001
|
| Hospital Charge Code |
3221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.20 |
| Max. Negotiated Rate |
$28.77 |
| Rate for Payer: Aetna Commercial |
$26.73
|
| Rate for Payer: Cash Price |
$18.56
|
| Rate for Payer: Cigna All Commercial |
$26.70
|
| Rate for Payer: CORVEL All Commercial |
$28.77
|
| Rate for Payer: Coventry All Commercial |
$27.23
|
| Rate for Payer: Encore All Commercial |
$28.48
|
| Rate for Payer: Frontpath All Commercial |
$28.46
|
| Rate for Payer: Humana ChoiceCare |
$26.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.85
|
| Rate for Payer: PHCS All Commercial |
$23.20
|
| Rate for Payer: PHP All Commercial |
$23.46
|
| Rate for Payer: Sagamore Health Network All Products |
$23.89
|
| Rate for Payer: Signature Care EPO |
$25.68
|
| Rate for Payer: Signature Care PPO |
$27.23
|
| Rate for Payer: United Healthcare Commercial |
$24.38
|
|
|
FLURBIPROFEN SODIUM 0.03 % OPHT DROP
|
Facility
|
IP
|
$236.11
|
|
|
Service Code
|
NDC 69292072225
|
| Hospital Charge Code |
10080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$177.08 |
| Max. Negotiated Rate |
$219.58 |
| Rate for Payer: Aetna Commercial |
$204.00
|
| Rate for Payer: Cash Price |
$141.67
|
| Rate for Payer: Cigna All Commercial |
$203.76
|
| Rate for Payer: CORVEL All Commercial |
$219.58
|
| Rate for Payer: Coventry All Commercial |
$207.78
|
| Rate for Payer: Encore All Commercial |
$217.34
|
| Rate for Payer: Frontpath All Commercial |
$217.22
|
| Rate for Payer: Humana ChoiceCare |
$203.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$212.50
|
| Rate for Payer: PHCS All Commercial |
$177.08
|
| Rate for Payer: PHP All Commercial |
$179.07
|
| Rate for Payer: Sagamore Health Network All Products |
$182.28
|
| Rate for Payer: Signature Care EPO |
$195.97
|
| Rate for Payer: Signature Care PPO |
$207.78
|
| Rate for Payer: United Healthcare Commercial |
$186.05
|
|
|
FLURBIPROFEN SODIUM 0.03 % OPHT DROP
|
Facility
|
OP
|
$236.11
|
|
|
Service Code
|
NDC 69292072225
|
| Hospital Charge Code |
10080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$219.58 |
| Rate for Payer: Aetna Commercial |
$199.28
|
| Rate for Payer: Aetna Medicare |
$75.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$73.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$135.60
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$147.59
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$86.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$83.11
|
| Rate for Payer: Cash Price |
$141.67
|
| Rate for Payer: Cash Price |
$141.67
|
| Rate for Payer: Centivo All Commercial |
$128.44
|
| Rate for Payer: Cigna All Commercial |
$203.76
|
| Rate for Payer: CORVEL All Commercial |
$219.58
|
| Rate for Payer: Coventry All Commercial |
$207.78
|
| Rate for Payer: Encore All Commercial |
$217.34
|
| Rate for Payer: Frontpath All Commercial |
$217.22
|
| Rate for Payer: Humana ChoiceCare |
$203.93
|
| Rate for Payer: Humana Medicare |
$75.56
|
| Rate for Payer: Lucent All Commercial |
$128.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$212.50
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$177.08
|
| Rate for Payer: PHP All Commercial |
$179.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$92.08
|
| Rate for Payer: Sagamore Health Network All Products |
$182.28
|
| Rate for Payer: Signature Care EPO |
$195.97
|
| Rate for Payer: Signature Care PPO |
$207.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$200.69
|
| Rate for Payer: United Healthcare Commercial |
$186.05
|
| Rate for Payer: United Healthcare Medicare |
$75.56
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASL SPSN
|
Facility
|
IP
|
$41.44
|
|
|
Service Code
|
NDC 60505082901
|
| Hospital Charge Code |
70536
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.08 |
| Max. Negotiated Rate |
$38.54 |
| Rate for Payer: Aetna Commercial |
$35.80
|
| Rate for Payer: Cash Price |
$24.86
|
| Rate for Payer: Cigna All Commercial |
$35.76
|
| Rate for Payer: CORVEL All Commercial |
$38.54
|
| Rate for Payer: Coventry All Commercial |
$36.47
|
| Rate for Payer: Encore All Commercial |
$38.15
|
| Rate for Payer: Frontpath All Commercial |
$38.12
|
| Rate for Payer: Humana ChoiceCare |
$35.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.30
|
| Rate for Payer: PHCS All Commercial |
$31.08
|
| Rate for Payer: PHP All Commercial |
$31.43
|
| Rate for Payer: Sagamore Health Network All Products |
$31.99
|
| Rate for Payer: Signature Care EPO |
$34.40
|
| Rate for Payer: Signature Care PPO |
$36.47
|
| Rate for Payer: United Healthcare Commercial |
$32.65
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASL SPSN
|
Facility
|
OP
|
$41.44
|
|
|
Service Code
|
NDC 60505082901
|
| Hospital Charge Code |
70536
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.85 |
| Max. Negotiated Rate |
$38.54 |
| Rate for Payer: Aetna Commercial |
$34.98
|
| Rate for Payer: Aetna Medicare |
$13.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$23.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$25.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.59
|
| Rate for Payer: Cash Price |
$24.86
|
| Rate for Payer: Centivo All Commercial |
$22.54
|
| Rate for Payer: Cigna All Commercial |
$35.76
|
| Rate for Payer: CORVEL All Commercial |
$38.54
|
| Rate for Payer: Coventry All Commercial |
$36.47
|
| Rate for Payer: Encore All Commercial |
$38.15
|
| Rate for Payer: Frontpath All Commercial |
$38.12
|
| Rate for Payer: Humana ChoiceCare |
$35.79
|
| Rate for Payer: Humana Medicare |
$13.26
|
| Rate for Payer: Lucent All Commercial |
$22.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.30
|
| Rate for Payer: PHCS All Commercial |
$31.08
|
| Rate for Payer: PHP All Commercial |
$31.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.16
|
| Rate for Payer: Sagamore Health Network All Products |
$31.99
|
| Rate for Payer: Signature Care EPO |
$34.40
|
| Rate for Payer: Signature Care PPO |
$36.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.22
|
| Rate for Payer: United Healthcare Commercial |
$32.65
|
| Rate for Payer: United Healthcare Medicare |
$13.26
|
|
|
FLU VACC TS2024-25(65YR UP)-PF 180 MCG/0.5 ML IM SYRG
|
Facility
|
IP
|
$396.77
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
205593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$297.58 |
| Max. Negotiated Rate |
$368.99 |
| Rate for Payer: Aetna Commercial |
$342.81
|
| Rate for Payer: Cash Price |
$238.06
|
| Rate for Payer: Cigna All Commercial |
$342.41
|
| Rate for Payer: CORVEL All Commercial |
$368.99
|
| Rate for Payer: Coventry All Commercial |
$349.16
|
| Rate for Payer: Encore All Commercial |
$365.22
|
| Rate for Payer: Frontpath All Commercial |
$365.03
|
| Rate for Payer: Humana ChoiceCare |
$342.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$357.09
|
| Rate for Payer: PHCS All Commercial |
$297.58
|
| Rate for Payer: PHP All Commercial |
$300.91
|
| Rate for Payer: Sagamore Health Network All Products |
$306.30
|
| Rate for Payer: Signature Care EPO |
$329.32
|
| Rate for Payer: Signature Care PPO |
$349.16
|
| Rate for Payer: United Healthcare Commercial |
$312.65
|
|
|
FLU VACC TS2024-25(65YR UP)-PF 180 MCG/0.5 ML IM SYRG
|
Facility
|
OP
|
$396.77
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
205593
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$123.00 |
| Max. Negotiated Rate |
$368.99 |
| Rate for Payer: Aetna Commercial |
$334.87
|
| Rate for Payer: Aetna Medicare |
$126.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$123.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$227.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$248.02
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$146.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$139.66
|
| Rate for Payer: Cash Price |
$238.06
|
| Rate for Payer: Centivo All Commercial |
$215.84
|
| Rate for Payer: Cigna All Commercial |
$342.41
|
| Rate for Payer: CORVEL All Commercial |
$368.99
|
| Rate for Payer: Coventry All Commercial |
$349.16
|
| Rate for Payer: Encore All Commercial |
$365.22
|
| Rate for Payer: Frontpath All Commercial |
$365.03
|
| Rate for Payer: Humana ChoiceCare |
$342.69
|
| Rate for Payer: Humana Medicare |
$126.97
|
| Rate for Payer: Lucent All Commercial |
$215.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$357.09
|
| Rate for Payer: PHCS All Commercial |
$297.58
|
| Rate for Payer: PHP All Commercial |
$300.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$154.74
|
| Rate for Payer: Sagamore Health Network All Products |
$306.30
|
| Rate for Payer: Signature Care EPO |
$329.32
|
| Rate for Payer: Signature Care PPO |
$349.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$337.25
|
| Rate for Payer: United Healthcare Commercial |
$312.65
|
| Rate for Payer: United Healthcare Medicare |
$126.97
|
|
|
FLU VACC TS2024-25 6MOS UP(PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG
|
Facility
|
IP
|
$138.11
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
205592
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.58 |
| Max. Negotiated Rate |
$128.44 |
| Rate for Payer: Aetna Commercial |
$119.33
|
| Rate for Payer: Cash Price |
$82.87
|
| Rate for Payer: Cigna All Commercial |
$119.19
|
| Rate for Payer: CORVEL All Commercial |
$128.44
|
| Rate for Payer: Coventry All Commercial |
$121.54
|
| Rate for Payer: Encore All Commercial |
$127.13
|
| Rate for Payer: Frontpath All Commercial |
$127.06
|
| Rate for Payer: Humana ChoiceCare |
$119.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$124.30
|
| Rate for Payer: PHCS All Commercial |
$103.58
|
| Rate for Payer: PHP All Commercial |
$104.74
|
| Rate for Payer: Sagamore Health Network All Products |
$106.62
|
| Rate for Payer: Signature Care EPO |
$114.63
|
| Rate for Payer: Signature Care PPO |
$121.54
|
| Rate for Payer: United Healthcare Commercial |
$108.83
|
|
|
FLU VACC TS2024-25 6MOS UP(PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG
|
Facility
|
OP
|
$138.11
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
205592
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$128.44 |
| Rate for Payer: Aetna Commercial |
$116.56
|
| Rate for Payer: Aetna Medicare |
$44.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$42.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$79.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$86.33
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$50.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$48.61
|
| Rate for Payer: Cash Price |
$82.87
|
| Rate for Payer: Centivo All Commercial |
$75.13
|
| Rate for Payer: Cigna All Commercial |
$119.19
|
| Rate for Payer: CORVEL All Commercial |
$128.44
|
| Rate for Payer: Coventry All Commercial |
$121.54
|
| Rate for Payer: Encore All Commercial |
$127.13
|
| Rate for Payer: Frontpath All Commercial |
$127.06
|
| Rate for Payer: Humana ChoiceCare |
$119.29
|
| Rate for Payer: Humana Medicare |
$44.20
|
| Rate for Payer: Lucent All Commercial |
$75.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$124.30
|
| Rate for Payer: PHCS All Commercial |
$103.58
|
| Rate for Payer: PHP All Commercial |
$104.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$53.86
|
| Rate for Payer: Sagamore Health Network All Products |
$106.62
|
| Rate for Payer: Signature Care EPO |
$114.63
|
| Rate for Payer: Signature Care PPO |
$121.54
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$117.39
|
| Rate for Payer: United Healthcare Commercial |
$108.83
|
| Rate for Payer: United Healthcare Medicare |
$44.20
|
|
|
FOLIC ACID 1 MG ORAL TAB
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
NDC 11534016501
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: Aetna Commercial |
$1.12
|
| Rate for Payer: Aetna Medicare |
$0.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.47
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Centivo All Commercial |
$0.72
|
| Rate for Payer: Cigna All Commercial |
$1.15
|
| Rate for Payer: CORVEL All Commercial |
$1.24
|
| Rate for Payer: Coventry All Commercial |
$1.17
|
| Rate for Payer: Encore All Commercial |
$1.22
|
| Rate for Payer: Frontpath All Commercial |
$1.22
|
| Rate for Payer: Humana ChoiceCare |
$1.15
|
| Rate for Payer: Humana Medicare |
$0.43
|
| Rate for Payer: Lucent All Commercial |
$0.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.20
|
| Rate for Payer: PHCS All Commercial |
$1.00
|
| Rate for Payer: PHP All Commercial |
$1.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.52
|
| Rate for Payer: Sagamore Health Network All Products |
$1.03
|
| Rate for Payer: Signature Care EPO |
$1.10
|
| Rate for Payer: Signature Care PPO |
$1.17
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.13
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
| Rate for Payer: United Healthcare Medicare |
$0.43
|
|
|
FOLIC ACID 1 MG ORAL TAB
|
Facility
|
IP
|
$1.33
|
|
|
Service Code
|
NDC 11534016501
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: Aetna Commercial |
$1.15
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna All Commercial |
$1.15
|
| Rate for Payer: CORVEL All Commercial |
$1.24
|
| Rate for Payer: Coventry All Commercial |
$1.17
|
| Rate for Payer: Encore All Commercial |
$1.22
|
| Rate for Payer: Frontpath All Commercial |
$1.22
|
| Rate for Payer: Humana ChoiceCare |
$1.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.20
|
| Rate for Payer: PHCS All Commercial |
$1.00
|
| Rate for Payer: PHP All Commercial |
$1.01
|
| Rate for Payer: Sagamore Health Network All Products |
$1.03
|
| Rate for Payer: Signature Care EPO |
$1.10
|
| Rate for Payer: Signature Care PPO |
$1.17
|
| Rate for Payer: United Healthcare Commercial |
$1.05
|
|
