|
FOLIC ACID 5 MG/ML INJ SOLN
|
Facility
|
IP
|
$315.36
|
|
|
Service Code
|
HCPCS J1808
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$236.52 |
| Max. Negotiated Rate |
$293.28 |
| Rate for Payer: Aetna Commercial |
$272.47
|
| Rate for Payer: Cash Price |
$189.22
|
| Rate for Payer: Cigna All Commercial |
$272.16
|
| Rate for Payer: CORVEL All Commercial |
$293.28
|
| Rate for Payer: Coventry All Commercial |
$277.52
|
| Rate for Payer: Encore All Commercial |
$290.29
|
| Rate for Payer: Frontpath All Commercial |
$290.13
|
| Rate for Payer: Humana ChoiceCare |
$272.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.82
|
| Rate for Payer: PHCS All Commercial |
$236.52
|
| Rate for Payer: PHP All Commercial |
$239.17
|
| Rate for Payer: Sagamore Health Network All Products |
$243.46
|
| Rate for Payer: Signature Care EPO |
$261.75
|
| Rate for Payer: Signature Care PPO |
$277.52
|
| Rate for Payer: United Healthcare Commercial |
$248.50
|
|
|
FOLIC ACID 5 MG/ML INJ SOLN
|
Facility
|
OP
|
$315.36
|
|
|
Service Code
|
HCPCS J1808
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.76 |
| Max. Negotiated Rate |
$293.28 |
| Rate for Payer: Aetna Commercial |
$266.16
|
| Rate for Payer: Aetna Medicare |
$100.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$97.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$181.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$197.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$116.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$111.01
|
| Rate for Payer: Cash Price |
$189.22
|
| Rate for Payer: Centivo All Commercial |
$171.56
|
| Rate for Payer: Cigna All Commercial |
$272.16
|
| Rate for Payer: CORVEL All Commercial |
$293.28
|
| Rate for Payer: Coventry All Commercial |
$277.52
|
| Rate for Payer: Encore All Commercial |
$290.29
|
| Rate for Payer: Frontpath All Commercial |
$290.13
|
| Rate for Payer: Humana ChoiceCare |
$272.38
|
| Rate for Payer: Humana Medicare |
$100.92
|
| Rate for Payer: Lucent All Commercial |
$171.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.82
|
| Rate for Payer: PHCS All Commercial |
$236.52
|
| Rate for Payer: PHP All Commercial |
$239.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$122.99
|
| Rate for Payer: Sagamore Health Network All Products |
$243.46
|
| Rate for Payer: Signature Care EPO |
$261.75
|
| Rate for Payer: Signature Care PPO |
$277.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$268.06
|
| Rate for Payer: United Healthcare Commercial |
$248.50
|
| Rate for Payer: United Healthcare Medicare |
$100.92
|
|
|
FOMEPIZOLE 1 G/ML IV SOLN
|
Facility
|
OP
|
$1,931.24
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
22185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.34 |
| Max. Negotiated Rate |
$1,796.05 |
| Rate for Payer: Aetna Commercial |
$1,629.96
|
| Rate for Payer: Aetna Medicare |
$618.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$598.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,109.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,207.22
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$10.34
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$710.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$679.80
|
| Rate for Payer: Cash Price |
$1,158.74
|
| Rate for Payer: Cash Price |
$1,158.74
|
| Rate for Payer: Centivo All Commercial |
$1,050.59
|
| Rate for Payer: Cigna All Commercial |
$1,666.66
|
| Rate for Payer: CORVEL All Commercial |
$1,796.05
|
| Rate for Payer: Coventry All Commercial |
$1,699.49
|
| Rate for Payer: Encore All Commercial |
$1,777.70
|
| Rate for Payer: Frontpath All Commercial |
$1,776.74
|
| Rate for Payer: Humana ChoiceCare |
$1,668.01
|
| Rate for Payer: Humana Medicare |
$618.00
|
| Rate for Payer: Lucent All Commercial |
$1,050.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,738.11
|
| Rate for Payer: Managed Health Services Medicaid |
$10.34
|
| Rate for Payer: MDWise Medicaid |
$10.34
|
| Rate for Payer: PHCS All Commercial |
$1,448.43
|
| Rate for Payer: PHP All Commercial |
$1,464.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$753.18
|
| Rate for Payer: Sagamore Health Network All Products |
$1,490.92
|
| Rate for Payer: Signature Care EPO |
$1,602.93
|
| Rate for Payer: Signature Care PPO |
$1,699.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,641.55
|
| Rate for Payer: United Healthcare Commercial |
$1,521.82
|
| Rate for Payer: United Healthcare Medicare |
$618.00
|
|
|
FOMEPIZOLE 1 G/ML IV SOLN
|
Facility
|
IP
|
$1,931.24
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
22185
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,448.43 |
| Max. Negotiated Rate |
$1,796.05 |
| Rate for Payer: Aetna Commercial |
$1,668.59
|
| Rate for Payer: Cash Price |
$1,158.74
|
| Rate for Payer: Cigna All Commercial |
$1,666.66
|
| Rate for Payer: CORVEL All Commercial |
$1,796.05
|
| Rate for Payer: Coventry All Commercial |
$1,699.49
|
| Rate for Payer: Encore All Commercial |
$1,777.70
|
| Rate for Payer: Frontpath All Commercial |
$1,776.74
|
| Rate for Payer: Humana ChoiceCare |
$1,668.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,738.11
|
| Rate for Payer: PHCS All Commercial |
$1,448.43
|
| Rate for Payer: PHP All Commercial |
$1,464.65
|
| Rate for Payer: Sagamore Health Network All Products |
$1,490.92
|
| Rate for Payer: Signature Care EPO |
$1,602.93
|
| Rate for Payer: Signature Care PPO |
$1,699.49
|
| Rate for Payer: United Healthcare Commercial |
$1,521.82
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBQ SYRG
|
Facility
|
IP
|
$65.75
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
32215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.31 |
| Max. Negotiated Rate |
$61.15 |
| Rate for Payer: Aetna Commercial |
$56.81
|
| Rate for Payer: Cash Price |
$39.45
|
| Rate for Payer: Cigna All Commercial |
$56.74
|
| Rate for Payer: CORVEL All Commercial |
$61.15
|
| Rate for Payer: Coventry All Commercial |
$57.86
|
| Rate for Payer: Encore All Commercial |
$60.52
|
| Rate for Payer: Frontpath All Commercial |
$60.49
|
| Rate for Payer: Humana ChoiceCare |
$56.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.18
|
| Rate for Payer: PHCS All Commercial |
$49.31
|
| Rate for Payer: PHP All Commercial |
$49.87
|
| Rate for Payer: Sagamore Health Network All Products |
$50.76
|
| Rate for Payer: Signature Care EPO |
$54.57
|
| Rate for Payer: Signature Care PPO |
$57.86
|
| Rate for Payer: United Healthcare Commercial |
$51.81
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBQ SYRG
|
Facility
|
OP
|
$65.75
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
32215
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$61.15 |
| Rate for Payer: Aetna Commercial |
$55.49
|
| Rate for Payer: Aetna Medicare |
$21.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$1.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$20.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$37.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$41.10
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$1.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$24.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$23.14
|
| Rate for Payer: Cash Price |
$39.45
|
| Rate for Payer: Cash Price |
$39.45
|
| Rate for Payer: Centivo All Commercial |
$35.77
|
| Rate for Payer: Cigna All Commercial |
$56.74
|
| Rate for Payer: CORVEL All Commercial |
$61.15
|
| Rate for Payer: Coventry All Commercial |
$57.86
|
| Rate for Payer: Encore All Commercial |
$60.52
|
| Rate for Payer: Frontpath All Commercial |
$60.49
|
| Rate for Payer: Humana ChoiceCare |
$56.79
|
| Rate for Payer: Humana Medicare |
$21.04
|
| Rate for Payer: Lucent All Commercial |
$35.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.18
|
| Rate for Payer: Managed Health Services Medicaid |
$1.84
|
| Rate for Payer: MDWise Medicaid |
$1.84
|
| Rate for Payer: PHCS All Commercial |
$49.31
|
| Rate for Payer: PHP All Commercial |
$49.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$25.64
|
| Rate for Payer: Sagamore Health Network All Products |
$50.76
|
| Rate for Payer: Signature Care EPO |
$54.57
|
| Rate for Payer: Signature Care PPO |
$57.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$55.89
|
| Rate for Payer: United Healthcare Commercial |
$51.81
|
| Rate for Payer: United Healthcare Medicare |
$21.04
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN
|
Facility
|
OP
|
$265.33
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.25 |
| Max. Negotiated Rate |
$246.76 |
| Rate for Payer: Aetna Commercial |
$223.94
|
| Rate for Payer: Aetna Medicare |
$84.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$82.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$152.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$165.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$97.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$93.40
|
| Rate for Payer: Cash Price |
$159.20
|
| Rate for Payer: Centivo All Commercial |
$144.34
|
| Rate for Payer: Cigna All Commercial |
$228.98
|
| Rate for Payer: CORVEL All Commercial |
$246.76
|
| Rate for Payer: Coventry All Commercial |
$233.49
|
| Rate for Payer: Encore All Commercial |
$244.23
|
| Rate for Payer: Frontpath All Commercial |
$244.10
|
| Rate for Payer: Humana ChoiceCare |
$229.16
|
| Rate for Payer: Humana Medicare |
$84.90
|
| Rate for Payer: Lucent All Commercial |
$144.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$238.80
|
| Rate for Payer: PHCS All Commercial |
$199.00
|
| Rate for Payer: PHP All Commercial |
$201.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$103.48
|
| Rate for Payer: Sagamore Health Network All Products |
$204.83
|
| Rate for Payer: Signature Care EPO |
$220.22
|
| Rate for Payer: Signature Care PPO |
$233.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$225.53
|
| Rate for Payer: United Healthcare Commercial |
$209.08
|
| Rate for Payer: United Healthcare Medicare |
$84.90
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN
|
Facility
|
IP
|
$265.33
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$199.00 |
| Max. Negotiated Rate |
$246.76 |
| Rate for Payer: Aetna Commercial |
$229.24
|
| Rate for Payer: Cash Price |
$159.20
|
| Rate for Payer: Cigna All Commercial |
$228.98
|
| Rate for Payer: CORVEL All Commercial |
$246.76
|
| Rate for Payer: Coventry All Commercial |
$233.49
|
| Rate for Payer: Encore All Commercial |
$244.23
|
| Rate for Payer: Frontpath All Commercial |
$244.10
|
| Rate for Payer: Humana ChoiceCare |
$229.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$238.80
|
| Rate for Payer: PHCS All Commercial |
$199.00
|
| Rate for Payer: PHP All Commercial |
$201.22
|
| Rate for Payer: Sagamore Health Network All Products |
$204.83
|
| Rate for Payer: Signature Care EPO |
$220.22
|
| Rate for Payer: Signature Care PPO |
$233.49
|
| Rate for Payer: United Healthcare Commercial |
$209.08
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN
|
Facility
|
IP
|
$568.55
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$426.41 |
| Max. Negotiated Rate |
$528.75 |
| Rate for Payer: Aetna Commercial |
$491.23
|
| Rate for Payer: Cash Price |
$341.13
|
| Rate for Payer: Cigna All Commercial |
$490.66
|
| Rate for Payer: CORVEL All Commercial |
$528.75
|
| Rate for Payer: Coventry All Commercial |
$500.32
|
| Rate for Payer: Encore All Commercial |
$523.35
|
| Rate for Payer: Frontpath All Commercial |
$523.07
|
| Rate for Payer: Humana ChoiceCare |
$491.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$511.69
|
| Rate for Payer: PHCS All Commercial |
$426.41
|
| Rate for Payer: PHP All Commercial |
$431.19
|
| Rate for Payer: Sagamore Health Network All Products |
$438.92
|
| Rate for Payer: Signature Care EPO |
$471.90
|
| Rate for Payer: Signature Care PPO |
$500.32
|
| Rate for Payer: United Healthcare Commercial |
$448.02
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN
|
Facility
|
OP
|
$568.55
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$176.25 |
| Max. Negotiated Rate |
$528.75 |
| Rate for Payer: Aetna Commercial |
$479.86
|
| Rate for Payer: Aetna Medicare |
$181.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$176.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$326.52
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$355.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$209.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$200.13
|
| Rate for Payer: Cash Price |
$341.13
|
| Rate for Payer: Centivo All Commercial |
$309.29
|
| Rate for Payer: Cigna All Commercial |
$490.66
|
| Rate for Payer: CORVEL All Commercial |
$528.75
|
| Rate for Payer: Coventry All Commercial |
$500.32
|
| Rate for Payer: Encore All Commercial |
$523.35
|
| Rate for Payer: Frontpath All Commercial |
$523.07
|
| Rate for Payer: Humana ChoiceCare |
$491.06
|
| Rate for Payer: Humana Medicare |
$181.94
|
| Rate for Payer: Lucent All Commercial |
$309.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$511.69
|
| Rate for Payer: PHCS All Commercial |
$426.41
|
| Rate for Payer: PHP All Commercial |
$431.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$221.73
|
| Rate for Payer: Sagamore Health Network All Products |
$438.92
|
| Rate for Payer: Signature Care EPO |
$471.90
|
| Rate for Payer: Signature Care PPO |
$500.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$483.27
|
| Rate for Payer: United Healthcare Commercial |
$448.02
|
| Rate for Payer: United Healthcare Medicare |
$181.94
|
|
|
FULVESTRANT 250 MG/5 ML IM SYRG
|
Facility
|
OP
|
$6,617.00
|
|
|
Service Code
|
HCPCS J9395
|
| Hospital Charge Code |
32767
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.88 |
| Max. Negotiated Rate |
$6,153.81 |
| Rate for Payer: Aetna Commercial |
$5,584.74
|
| Rate for Payer: Aetna Medicare |
$2,117.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$7.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,051.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3,800.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,136.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$7.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,435.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,329.18
|
| Rate for Payer: Cash Price |
$3,970.20
|
| Rate for Payer: Cash Price |
$3,970.20
|
| Rate for Payer: Centivo All Commercial |
$3,599.65
|
| Rate for Payer: Cigna All Commercial |
$5,710.47
|
| Rate for Payer: CORVEL All Commercial |
$6,153.81
|
| Rate for Payer: Coventry All Commercial |
$5,822.96
|
| Rate for Payer: Encore All Commercial |
$6,090.94
|
| Rate for Payer: Frontpath All Commercial |
$6,087.64
|
| Rate for Payer: Humana ChoiceCare |
$5,715.10
|
| Rate for Payer: Humana Medicare |
$2,117.44
|
| Rate for Payer: Lucent All Commercial |
$3,599.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,955.30
|
| Rate for Payer: Managed Health Services Medicaid |
$7.88
|
| Rate for Payer: MDWise Medicaid |
$7.88
|
| Rate for Payer: PHCS All Commercial |
$4,962.75
|
| Rate for Payer: PHP All Commercial |
$5,018.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,580.63
|
| Rate for Payer: Sagamore Health Network All Products |
$5,108.32
|
| Rate for Payer: Signature Care EPO |
$5,492.11
|
| Rate for Payer: Signature Care PPO |
$5,822.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,624.45
|
| Rate for Payer: United Healthcare Commercial |
$5,214.19
|
| Rate for Payer: United Healthcare Medicare |
$2,117.44
|
|
|
FULVESTRANT 250 MG/5 ML IM SYRG
|
Facility
|
IP
|
$6,617.00
|
|
|
Service Code
|
HCPCS J9395
|
| Hospital Charge Code |
32767
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,962.75 |
| Max. Negotiated Rate |
$6,153.81 |
| Rate for Payer: Aetna Commercial |
$5,717.08
|
| Rate for Payer: Cash Price |
$3,970.20
|
| Rate for Payer: Cigna All Commercial |
$5,710.47
|
| Rate for Payer: CORVEL All Commercial |
$6,153.81
|
| Rate for Payer: Coventry All Commercial |
$5,822.96
|
| Rate for Payer: Encore All Commercial |
$6,090.94
|
| Rate for Payer: Frontpath All Commercial |
$6,087.64
|
| Rate for Payer: Humana ChoiceCare |
$5,715.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,955.30
|
| Rate for Payer: PHCS All Commercial |
$4,962.75
|
| Rate for Payer: PHP All Commercial |
$5,018.33
|
| Rate for Payer: Sagamore Health Network All Products |
$5,108.32
|
| Rate for Payer: Signature Care EPO |
$5,492.11
|
| Rate for Payer: Signature Care PPO |
$5,822.96
|
| Rate for Payer: United Healthcare Commercial |
$5,214.19
|
|
|
FUROSEMIDE 10 MG/ML INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
3291
|
|
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
|
|
|
FUROSEMIDE 10 MG/ML INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
3291
|
|
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
|
|
|
FUROSEMIDE 20 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904717761
|
| Hospital Charge Code |
3294
|
|
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
|
|
|
FUROSEMIDE 20 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904717761
|
| Hospital Charge Code |
3294
|
|
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
|
|
|
FUROSEMIDE 40 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904717861
|
| Hospital Charge Code |
3295
|
|
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
|
|
|
FUROSEMIDE 40 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904717861
|
| Hospital Charge Code |
3295
|
|
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
|
|
|
GABAPENTIN 100 MG ORAL CAP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904666561
|
| Hospital Charge Code |
18309
|
|
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
|
|
|
GABAPENTIN 100 MG ORAL CAP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904666561
|
| Hospital Charge Code |
18309
|
|
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
|
|
|
GABAPENTIN 300 MG ORAL CAP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687059111
|
| Hospital Charge Code |
18308
|
|
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
|
|
|
GABAPENTIN 300 MG ORAL CAP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687059101
|
| Hospital Charge Code |
18308
|
|
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
|
|
|
GABAPENTIN 300 MG ORAL CAP
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687059101
|
| Hospital Charge Code |
18308
|
|
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
|
|
|
GABAPENTIN 300 MG ORAL CAP
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687059111
|
| Hospital Charge Code |
18308
|
|
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
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN 10 ML VIAL
|
Facility
|
IP
|
$348.96
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$261.72 |
| Max. Negotiated Rate |
$324.53 |
| Rate for Payer: Aetna Commercial |
$301.50
|
| Rate for Payer: Cash Price |
$209.38
|
| Rate for Payer: Cigna All Commercial |
$301.15
|
| Rate for Payer: CORVEL All Commercial |
$324.53
|
| Rate for Payer: Coventry All Commercial |
$307.08
|
| Rate for Payer: Encore All Commercial |
$321.22
|
| Rate for Payer: Frontpath All Commercial |
$321.04
|
| Rate for Payer: Humana ChoiceCare |
$301.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$314.06
|
| Rate for Payer: PHCS All Commercial |
$261.72
|
| Rate for Payer: PHP All Commercial |
$264.65
|
| Rate for Payer: Sagamore Health Network All Products |
$269.40
|
| Rate for Payer: Signature Care EPO |
$289.64
|
| Rate for Payer: Signature Care PPO |
$307.08
|
| Rate for Payer: United Healthcare Commercial |
$274.98
|
|
