|
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
119375
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
119375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
FAMOTIDINE (PF)-NACL (ISO-OS) 20 MG/50 ML IV PGBK
|
Facility
OP
|
$39.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
12735
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.94 |
| Max. Negotiated Rate |
$36.46 |
| Rate for Payer: Aetna Commercial |
$33.08
|
| Rate for Payer: Aetna Medicare |
$12.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$22.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.23
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Centivo All Commercial |
$19.99
|
| Rate for Payer: Cigna All Commercial |
$33.83
|
| Rate for Payer: CORVEL All Commercial |
$36.46
|
| Rate for Payer: Coventry All Commercial |
$34.50
|
| Rate for Payer: Encore All Commercial |
$36.08
|
| Rate for Payer: Frontpath All Commercial |
$36.06
|
| Rate for Payer: Humana ChoiceCare |
$33.86
|
| Rate for Payer: Humana Medicare |
$19.99
|
| Rate for Payer: Lucent All Commercial |
$19.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.28
|
| Rate for Payer: PHCS All Commercial |
$29.40
|
| Rate for Payer: PHP All Commercial |
$29.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.29
|
| Rate for Payer: Sagamore Health Network All Products |
$30.26
|
| Rate for Payer: Signature Care EPO |
$32.54
|
| Rate for Payer: Signature Care PPO |
$34.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$33.32
|
| Rate for Payer: United Healthcare Commercial |
$30.89
|
| Rate for Payer: United Healthcare Medicare |
$12.94
|
|
|
FAMOTIDINE (PF)-NACL (ISO-OS) 20 MG/50 ML IV PGBK
|
Facility
IP
|
$39.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
12735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$36.46 |
| Rate for Payer: Aetna Commercial |
$33.87
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna All Commercial |
$33.83
|
| Rate for Payer: CORVEL All Commercial |
$36.46
|
| Rate for Payer: Coventry All Commercial |
$34.50
|
| Rate for Payer: Encore All Commercial |
$36.08
|
| Rate for Payer: Frontpath All Commercial |
$36.06
|
| Rate for Payer: Humana ChoiceCare |
$33.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.28
|
| Rate for Payer: PHCS All Commercial |
$29.40
|
| Rate for Payer: PHP All Commercial |
$29.73
|
| Rate for Payer: Sagamore Health Network All Products |
$30.26
|
| Rate for Payer: Signature Care EPO |
$32.54
|
| Rate for Payer: Signature Care PPO |
$34.50
|
| Rate for Payer: United Healthcare Commercial |
$30.89
|
|
|
FAT EMULSION 20 % IV EMUL
|
Facility
OP
|
$290.50
|
|
|
Service Code
|
NDC 00338051913
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$74.57 |
| Max. Negotiated Rate |
$270.16 |
| Rate for Payer: Aetna Commercial |
$245.18
|
| Rate for Payer: Aetna Medicare |
$95.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$95.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$166.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$181.59
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$74.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$110.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$105.45
|
| Rate for Payer: Cash Price |
$180.11
|
| Rate for Payer: Cash Price |
$180.11
|
| Rate for Payer: Centivo All Commercial |
$148.16
|
| Rate for Payer: Cigna All Commercial |
$250.70
|
| Rate for Payer: CORVEL All Commercial |
$270.16
|
| Rate for Payer: Coventry All Commercial |
$255.64
|
| Rate for Payer: Encore All Commercial |
$267.41
|
| Rate for Payer: Frontpath All Commercial |
$267.26
|
| Rate for Payer: Humana ChoiceCare |
$250.90
|
| Rate for Payer: Humana Medicare |
$148.16
|
| Rate for Payer: Lucent All Commercial |
$148.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$261.45
|
| Rate for Payer: Managed Health Services Medicaid |
$74.57
|
| Rate for Payer: MDWise Medicaid |
$74.57
|
| Rate for Payer: PHCS All Commercial |
$217.88
|
| Rate for Payer: PHP All Commercial |
$220.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$113.30
|
| Rate for Payer: Sagamore Health Network All Products |
$224.27
|
| Rate for Payer: Signature Care EPO |
$241.12
|
| Rate for Payer: Signature Care PPO |
$255.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$246.92
|
| Rate for Payer: United Healthcare Commercial |
$228.91
|
| Rate for Payer: United Healthcare Medicare |
$95.86
|
|
|
FAT EMULSION 20 % IV EMUL
|
Facility
IP
|
$290.50
|
|
|
Service Code
|
NDC 00338051913
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$217.88 |
| Max. Negotiated Rate |
$270.16 |
| Rate for Payer: Aetna Commercial |
$250.99
|
| Rate for Payer: Cash Price |
$180.11
|
| Rate for Payer: Cigna All Commercial |
$250.70
|
| Rate for Payer: CORVEL All Commercial |
$270.16
|
| Rate for Payer: Coventry All Commercial |
$255.64
|
| Rate for Payer: Encore All Commercial |
$267.41
|
| Rate for Payer: Frontpath All Commercial |
$267.26
|
| Rate for Payer: Humana ChoiceCare |
$250.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$261.45
|
| Rate for Payer: PHCS All Commercial |
$217.88
|
| Rate for Payer: PHP All Commercial |
$220.32
|
| Rate for Payer: Sagamore Health Network All Products |
$224.27
|
| Rate for Payer: Signature Care EPO |
$241.12
|
| Rate for Payer: Signature Care PPO |
$255.64
|
| Rate for Payer: United Healthcare Commercial |
$228.91
|
|
|
FEBUXOSTAT 40 MG ORAL TAB
|
Facility
IP
|
$14.72
|
|
|
Service Code
|
NDC 60687053821
|
| Hospital Charge Code |
97133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.04 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna Commercial |
$12.72
|
| Rate for Payer: Cash Price |
$9.13
|
| Rate for Payer: Cigna All Commercial |
$12.70
|
| Rate for Payer: CORVEL All Commercial |
$13.69
|
| Rate for Payer: Coventry All Commercial |
$12.95
|
| Rate for Payer: Encore All Commercial |
$13.55
|
| Rate for Payer: Frontpath All Commercial |
$13.54
|
| Rate for Payer: Humana ChoiceCare |
$12.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.25
|
| Rate for Payer: PHCS All Commercial |
$11.04
|
| Rate for Payer: PHP All Commercial |
$11.16
|
| Rate for Payer: Sagamore Health Network All Products |
$11.36
|
| Rate for Payer: Signature Care EPO |
$12.22
|
| Rate for Payer: Signature Care PPO |
$12.95
|
| Rate for Payer: United Healthcare Commercial |
$11.60
|
|
|
FEBUXOSTAT 40 MG ORAL TAB
|
Facility
OP
|
$14.72
|
|
|
Service Code
|
NDC 60687053821
|
| Hospital Charge Code |
97133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna Commercial |
$12.42
|
| Rate for Payer: Aetna Medicare |
$4.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.34
|
| Rate for Payer: Cash Price |
$9.13
|
| Rate for Payer: Centivo All Commercial |
$7.51
|
| Rate for Payer: Cigna All Commercial |
$12.70
|
| Rate for Payer: CORVEL All Commercial |
$13.69
|
| Rate for Payer: Coventry All Commercial |
$12.95
|
| Rate for Payer: Encore All Commercial |
$13.55
|
| Rate for Payer: Frontpath All Commercial |
$13.54
|
| Rate for Payer: Humana ChoiceCare |
$12.71
|
| Rate for Payer: Humana Medicare |
$7.51
|
| Rate for Payer: Lucent All Commercial |
$7.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.25
|
| Rate for Payer: PHCS All Commercial |
$11.04
|
| Rate for Payer: PHP All Commercial |
$11.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.74
|
| Rate for Payer: Sagamore Health Network All Products |
$11.36
|
| Rate for Payer: Signature Care EPO |
$12.22
|
| Rate for Payer: Signature Care PPO |
$12.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.51
|
| Rate for Payer: United Healthcare Commercial |
$11.60
|
| Rate for Payer: United Healthcare Medicare |
$4.86
|
|
|
FENOFIBRATE 54 MG ORAL TAB
|
Facility
OP
|
$7.20
|
|
|
Service Code
|
NDC 60687065521
|
| Hospital Charge Code |
31336
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.08
|
| Rate for Payer: Aetna Medicare |
$2.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.61
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Centivo All Commercial |
$3.67
|
| Rate for Payer: Cigna All Commercial |
$6.22
|
| Rate for Payer: CORVEL All Commercial |
$6.70
|
| Rate for Payer: Coventry All Commercial |
$6.34
|
| Rate for Payer: Encore All Commercial |
$6.63
|
| Rate for Payer: Frontpath All Commercial |
$6.63
|
| Rate for Payer: Humana ChoiceCare |
$6.22
|
| Rate for Payer: Humana Medicare |
$3.67
|
| Rate for Payer: Lucent All Commercial |
$3.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.48
|
| Rate for Payer: PHCS All Commercial |
$5.40
|
| Rate for Payer: PHP All Commercial |
$5.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.81
|
| Rate for Payer: Sagamore Health Network All Products |
$5.56
|
| Rate for Payer: Signature Care EPO |
$5.98
|
| Rate for Payer: Signature Care PPO |
$6.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.12
|
| Rate for Payer: United Healthcare Commercial |
$5.68
|
| Rate for Payer: United Healthcare Medicare |
$2.38
|
|
|
FENOFIBRATE 54 MG ORAL TAB
|
Facility
IP
|
$7.20
|
|
|
Service Code
|
NDC 60687065521
|
| Hospital Charge Code |
31336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.22
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Cigna All Commercial |
$6.22
|
| Rate for Payer: CORVEL All Commercial |
$6.70
|
| Rate for Payer: Coventry All Commercial |
$6.34
|
| Rate for Payer: Encore All Commercial |
$6.63
|
| Rate for Payer: Frontpath All Commercial |
$6.63
|
| Rate for Payer: Humana ChoiceCare |
$6.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.48
|
| Rate for Payer: PHCS All Commercial |
$5.40
|
| Rate for Payer: PHP All Commercial |
$5.46
|
| Rate for Payer: Sagamore Health Network All Products |
$5.56
|
| Rate for Payer: Signature Care EPO |
$5.98
|
| Rate for Payer: Signature Care PPO |
$6.34
|
| Rate for Payer: United Healthcare Commercial |
$5.68
|
|
|
FENTANYL 100 MCG/HR TD PT72
|
Facility
IP
|
$183.26
|
|
|
Service Code
|
NDC 00406900076
|
| Hospital Charge Code |
27908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$137.44 |
| Max. Negotiated Rate |
$170.43 |
| Rate for Payer: Aetna Commercial |
$158.34
|
| Rate for Payer: Cash Price |
$113.62
|
| Rate for Payer: Cigna All Commercial |
$158.15
|
| Rate for Payer: CORVEL All Commercial |
$170.43
|
| Rate for Payer: Coventry All Commercial |
$161.27
|
| Rate for Payer: Encore All Commercial |
$168.69
|
| Rate for Payer: Frontpath All Commercial |
$168.60
|
| Rate for Payer: Humana ChoiceCare |
$158.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$164.93
|
| Rate for Payer: PHCS All Commercial |
$137.44
|
| Rate for Payer: PHP All Commercial |
$138.98
|
| Rate for Payer: Sagamore Health Network All Products |
$141.48
|
| Rate for Payer: Signature Care EPO |
$152.11
|
| Rate for Payer: Signature Care PPO |
$161.27
|
| Rate for Payer: United Healthcare Commercial |
$144.41
|
|
|
FENTANYL 100 MCG/HR TD PT72
|
Facility
OP
|
$183.26
|
|
|
Service Code
|
NDC 00406900076
|
| Hospital Charge Code |
27908
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.48 |
| Max. Negotiated Rate |
$170.43 |
| Rate for Payer: Aetna Commercial |
$154.67
|
| Rate for Payer: Aetna Medicare |
$60.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$60.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$105.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$114.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$69.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$66.52
|
| Rate for Payer: Cash Price |
$113.62
|
| Rate for Payer: Centivo All Commercial |
$93.46
|
| Rate for Payer: Cigna All Commercial |
$158.15
|
| Rate for Payer: CORVEL All Commercial |
$170.43
|
| Rate for Payer: Coventry All Commercial |
$161.27
|
| Rate for Payer: Encore All Commercial |
$168.69
|
| Rate for Payer: Frontpath All Commercial |
$168.60
|
| Rate for Payer: Humana ChoiceCare |
$158.28
|
| Rate for Payer: Humana Medicare |
$93.46
|
| Rate for Payer: Lucent All Commercial |
$93.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$164.93
|
| Rate for Payer: PHCS All Commercial |
$137.44
|
| Rate for Payer: PHP All Commercial |
$138.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$71.47
|
| Rate for Payer: Sagamore Health Network All Products |
$141.48
|
| Rate for Payer: Signature Care EPO |
$152.11
|
| Rate for Payer: Signature Care PPO |
$161.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$155.77
|
| Rate for Payer: United Healthcare Commercial |
$144.41
|
| Rate for Payer: United Healthcare Medicare |
$60.48
|
|
|
FENTANYL 12 MCG/HR TD PT72
|
Facility
IP
|
$53.70
|
|
|
Service Code
|
NDC 00378911998
|
| Hospital Charge Code |
41382
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.28 |
| Max. Negotiated Rate |
$49.94 |
| Rate for Payer: Aetna Commercial |
$46.40
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna All Commercial |
$46.35
|
| Rate for Payer: CORVEL All Commercial |
$49.94
|
| Rate for Payer: Coventry All Commercial |
$47.26
|
| Rate for Payer: Encore All Commercial |
$49.43
|
| Rate for Payer: Frontpath All Commercial |
$49.41
|
| Rate for Payer: Humana ChoiceCare |
$46.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.33
|
| Rate for Payer: PHCS All Commercial |
$40.28
|
| Rate for Payer: PHP All Commercial |
$40.73
|
| Rate for Payer: Sagamore Health Network All Products |
$41.46
|
| Rate for Payer: Signature Care EPO |
$44.57
|
| Rate for Payer: Signature Care PPO |
$47.26
|
| Rate for Payer: United Healthcare Commercial |
$42.32
|
|
|
FENTANYL 12 MCG/HR TD PT72
|
Facility
OP
|
$53.70
|
|
|
Service Code
|
NDC 00378911998
|
| Hospital Charge Code |
41382
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.72 |
| Max. Negotiated Rate |
$49.94 |
| Rate for Payer: Aetna Commercial |
$45.33
|
| Rate for Payer: Aetna Medicare |
$17.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$30.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$33.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$20.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.49
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Centivo All Commercial |
$27.39
|
| Rate for Payer: Cigna All Commercial |
$46.35
|
| Rate for Payer: CORVEL All Commercial |
$49.94
|
| Rate for Payer: Coventry All Commercial |
$47.26
|
| Rate for Payer: Encore All Commercial |
$49.43
|
| Rate for Payer: Frontpath All Commercial |
$49.41
|
| Rate for Payer: Humana ChoiceCare |
$46.38
|
| Rate for Payer: Humana Medicare |
$27.39
|
| Rate for Payer: Lucent All Commercial |
$27.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.33
|
| Rate for Payer: PHCS All Commercial |
$40.28
|
| Rate for Payer: PHP All Commercial |
$40.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$20.94
|
| Rate for Payer: Sagamore Health Network All Products |
$41.46
|
| Rate for Payer: Signature Care EPO |
$44.57
|
| Rate for Payer: Signature Care PPO |
$47.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$45.65
|
| Rate for Payer: United Healthcare Commercial |
$42.32
|
| Rate for Payer: United Healthcare Medicare |
$17.72
|
|
|
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 |
$29.40
|
| 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 00378912198
|
| Hospital Charge Code |
27905
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.65 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$40.02
|
| Rate for Payer: Aetna Medicare |
$15.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$27.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.21
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Centivo All Commercial |
$24.18
|
| 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 |
$24.18
|
| Rate for Payer: Lucent All Commercial |
$24.18
|
| 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 |
$15.65
|
|
|
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 |
$15.65 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$40.02
|
| Rate for Payer: Aetna Medicare |
$15.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$27.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.21
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Centivo All Commercial |
$24.18
|
| 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 |
$24.18
|
| Rate for Payer: Lucent All Commercial |
$24.18
|
| 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 |
$15.65
|
|
|
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 |
$29.40
|
| 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 4 MCG/0.4 ML SYRINGE - DILUTION (CAMERON)
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
NDC 00000003635
|
| Hospital Charge Code |
1401000800214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
FENTANYL 4 MCG/0.4 ML SYRINGE - DILUTION (CAMERON)
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
NDC 00000003635
|
| Hospital Charge Code |
1401000800214
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
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 |
$52.22
|
| 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 50 MCG/HR TD PT72
|
Facility
OP
|
$84.22
|
|
|
Service Code
|
NDC 00378912298
|
| Hospital Charge Code |
27906
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.79 |
| Max. Negotiated Rate |
$78.33 |
| Rate for Payer: Aetna Commercial |
$71.09
|
| Rate for Payer: Aetna Medicare |
$27.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$27.79
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$48.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$52.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$31.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$30.57
|
| Rate for Payer: Cash Price |
$52.22
|
| Rate for Payer: Centivo All Commercial |
$42.95
|
| 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 |
$42.95
|
| Rate for Payer: Lucent All Commercial |
$42.95
|
| 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 |
$27.79
|
|
|
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 |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
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 |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
FENTANYL CITRATE (PF) 50 MCG/ML PEDIATRIC INTRANASAL SOLN (CAMERON)
|
Facility
IP
|
$12.22
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
140160205301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.16 |
| Max. Negotiated Rate |
$11.36 |
| Rate for Payer: Aetna Commercial |
$10.55
|
| Rate for Payer: Cash Price |
$7.57
|
| Rate for Payer: Cigna All Commercial |
$10.54
|
| Rate for Payer: CORVEL All Commercial |
$11.36
|
| Rate for Payer: Coventry All Commercial |
$10.75
|
| Rate for Payer: Encore All Commercial |
$11.24
|
| Rate for Payer: Frontpath All Commercial |
$11.24
|
| Rate for Payer: Humana ChoiceCare |
$10.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.99
|
| Rate for Payer: PHCS All Commercial |
$9.16
|
| Rate for Payer: PHP All Commercial |
$9.26
|
| Rate for Payer: Sagamore Health Network All Products |
$9.43
|
| Rate for Payer: Signature Care EPO |
$10.14
|
| Rate for Payer: Signature Care PPO |
$10.75
|
| Rate for Payer: United Healthcare Commercial |
$9.63
|
|
