|
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG
|
Facility
|
OP
|
$1,070.00
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
174011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$995.10 |
| Rate for Payer: Aetna Commercial |
$903.08
|
| Rate for Payer: Aetna Medicare |
$353.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$353.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$614.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$668.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$0.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$406.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$388.41
|
| Rate for Payer: Cash Price |
$663.40
|
| Rate for Payer: Cash Price |
$663.40
|
| Rate for Payer: Centivo All Commercial |
$545.70
|
| Rate for Payer: Cigna All Commercial |
$923.41
|
| Rate for Payer: CORVEL All Commercial |
$995.10
|
| Rate for Payer: Coventry All Commercial |
$941.60
|
| Rate for Payer: Encore All Commercial |
$984.94
|
| Rate for Payer: Frontpath All Commercial |
$984.40
|
| Rate for Payer: Humana ChoiceCare |
$924.16
|
| Rate for Payer: Humana Medicare |
$545.70
|
| Rate for Payer: Lucent All Commercial |
$545.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$963.00
|
| Rate for Payer: Managed Health Services Medicaid |
$0.96
|
| Rate for Payer: MDWise Medicaid |
$0.96
|
| Rate for Payer: PHCS All Commercial |
$802.50
|
| Rate for Payer: PHP All Commercial |
$811.49
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$417.30
|
| Rate for Payer: Sagamore Health Network All Products |
$826.04
|
| Rate for Payer: Signature Care EPO |
$888.10
|
| Rate for Payer: Signature Care PPO |
$941.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$909.50
|
| Rate for Payer: United Healthcare Commercial |
$843.16
|
| Rate for Payer: United Healthcare Medicare |
$353.10
|
|
|
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG
|
Facility
|
OP
|
$1,712.04
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
174010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1,592.20 |
| Rate for Payer: Aetna Commercial |
$1,444.96
|
| Rate for Payer: Aetna Medicare |
$564.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$564.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$983.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,070.20
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$0.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$649.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$621.47
|
| Rate for Payer: Cash Price |
$1,061.47
|
| Rate for Payer: Cash Price |
$1,061.47
|
| Rate for Payer: Centivo All Commercial |
$873.14
|
| Rate for Payer: Cigna All Commercial |
$1,477.49
|
| Rate for Payer: CORVEL All Commercial |
$1,592.20
|
| Rate for Payer: Coventry All Commercial |
$1,506.60
|
| Rate for Payer: Encore All Commercial |
$1,575.93
|
| Rate for Payer: Frontpath All Commercial |
$1,575.08
|
| Rate for Payer: Humana ChoiceCare |
$1,478.69
|
| Rate for Payer: Humana Medicare |
$873.14
|
| Rate for Payer: Lucent All Commercial |
$873.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,540.84
|
| Rate for Payer: Managed Health Services Medicaid |
$0.96
|
| Rate for Payer: MDWise Medicaid |
$0.96
|
| Rate for Payer: PHCS All Commercial |
$1,284.03
|
| Rate for Payer: PHP All Commercial |
$1,298.41
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$667.70
|
| Rate for Payer: Sagamore Health Network All Products |
$1,321.70
|
| Rate for Payer: Signature Care EPO |
$1,420.99
|
| Rate for Payer: Signature Care PPO |
$1,506.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,455.24
|
| Rate for Payer: United Healthcare Commercial |
$1,349.09
|
| Rate for Payer: United Healthcare Medicare |
$564.97
|
|
|
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG
|
Facility
|
IP
|
$1,712.04
|
|
|
Service Code
|
HCPCS Q5101
|
| Hospital Charge Code |
174010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,284.03 |
| Max. Negotiated Rate |
$1,592.20 |
| Rate for Payer: Aetna Commercial |
$1,479.20
|
| Rate for Payer: Cash Price |
$1,061.47
|
| Rate for Payer: Cigna All Commercial |
$1,477.49
|
| Rate for Payer: CORVEL All Commercial |
$1,592.20
|
| Rate for Payer: Coventry All Commercial |
$1,506.60
|
| Rate for Payer: Encore All Commercial |
$1,575.93
|
| Rate for Payer: Frontpath All Commercial |
$1,575.08
|
| Rate for Payer: Humana ChoiceCare |
$1,478.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,540.84
|
| Rate for Payer: PHCS All Commercial |
$1,284.03
|
| Rate for Payer: PHP All Commercial |
$1,298.41
|
| Rate for Payer: Sagamore Health Network All Products |
$1,321.70
|
| Rate for Payer: Signature Care EPO |
$1,420.99
|
| Rate for Payer: Signature Care PPO |
$1,506.60
|
| Rate for Payer: United Healthcare Commercial |
$1,349.09
|
|
|
FINASTERIDE 5 MG ORAL TAB
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904683061
|
| Hospital Charge Code |
10037
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$2.79 |
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Cigna All Commercial |
$2.59
|
| Rate for Payer: CORVEL All Commercial |
$2.79
|
| Rate for Payer: Coventry All Commercial |
$2.64
|
| Rate for Payer: Encore All Commercial |
$2.76
|
| Rate for Payer: Frontpath All Commercial |
$2.76
|
| Rate for Payer: Humana ChoiceCare |
$2.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.70
|
| Rate for Payer: PHCS All Commercial |
$2.25
|
| Rate for Payer: PHP All Commercial |
$2.28
|
| Rate for Payer: Sagamore Health Network All Products |
$2.32
|
| Rate for Payer: Signature Care EPO |
$2.49
|
| Rate for Payer: Signature Care PPO |
$2.64
|
| Rate for Payer: United Healthcare Commercial |
$2.37
|
|
|
FINASTERIDE 5 MG ORAL TAB
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904683061
|
| Hospital Charge Code |
10037
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$2.79 |
| Rate for Payer: Aetna Commercial |
$2.53
|
| Rate for Payer: Aetna Medicare |
$0.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.09
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Centivo All Commercial |
$1.53
|
| Rate for Payer: Cigna All Commercial |
$2.59
|
| Rate for Payer: CORVEL All Commercial |
$2.79
|
| Rate for Payer: Coventry All Commercial |
$2.64
|
| Rate for Payer: Encore All Commercial |
$2.76
|
| Rate for Payer: Frontpath All Commercial |
$2.76
|
| Rate for Payer: Humana ChoiceCare |
$2.59
|
| Rate for Payer: Humana Medicare |
$1.53
|
| Rate for Payer: Lucent All Commercial |
$1.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.70
|
| Rate for Payer: PHCS All Commercial |
$2.25
|
| Rate for Payer: PHP All Commercial |
$2.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.17
|
| Rate for Payer: Sagamore Health Network All Products |
$2.32
|
| Rate for Payer: Signature Care EPO |
$2.49
|
| Rate for Payer: Signature Care PPO |
$2.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.55
|
| Rate for Payer: United Healthcare Commercial |
$2.37
|
| Rate for Payer: United Healthcare Medicare |
$0.99
|
|
|
Fine needle aspiration biopsy, including ultrasound guidance; first lesion
|
Facility
|
OP
|
$2,273.62
|
|
|
Service Code
|
CPT 10005
|
| Hospital Charge Code |
CPT-10005
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,273.62 |
| Max. Negotiated Rate |
$2,273.62 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$2,273.62
|
| Rate for Payer: Managed Health Services Medicaid |
$2,273.62
|
| Rate for Payer: MDWise Medicaid |
$2,273.62
|
|
|
FLECAINIDE 50 MG ORAL TAB
|
Facility
|
IP
|
$3.83
|
|
|
Service Code
|
NDC 00054001020
|
| Hospital Charge Code |
10043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna Commercial |
$3.31
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna All Commercial |
$3.30
|
| Rate for Payer: CORVEL All Commercial |
$3.56
|
| Rate for Payer: Coventry All Commercial |
$3.37
|
| Rate for Payer: Encore All Commercial |
$3.52
|
| Rate for Payer: Frontpath All Commercial |
$3.52
|
| Rate for Payer: Humana ChoiceCare |
$3.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.45
|
| Rate for Payer: PHCS All Commercial |
$2.87
|
| Rate for Payer: PHP All Commercial |
$2.90
|
| Rate for Payer: Sagamore Health Network All Products |
$2.96
|
| Rate for Payer: Signature Care EPO |
$3.18
|
| Rate for Payer: Signature Care PPO |
$3.37
|
| Rate for Payer: United Healthcare Commercial |
$3.02
|
|
|
FLECAINIDE 50 MG ORAL TAB
|
Facility
|
OP
|
$3.83
|
|
|
Service Code
|
NDC 00054001020
|
| Hospital Charge Code |
10043
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna Commercial |
$3.23
|
| Rate for Payer: Aetna Medicare |
$1.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.26
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.39
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.39
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Centivo All Commercial |
$1.95
|
| Rate for Payer: Cigna All Commercial |
$3.30
|
| Rate for Payer: CORVEL All Commercial |
$3.56
|
| Rate for Payer: Coventry All Commercial |
$3.37
|
| Rate for Payer: Encore All Commercial |
$3.52
|
| Rate for Payer: Frontpath All Commercial |
$3.52
|
| Rate for Payer: Humana ChoiceCare |
$3.31
|
| Rate for Payer: Humana Medicare |
$1.95
|
| Rate for Payer: Lucent All Commercial |
$1.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.45
|
| Rate for Payer: PHCS All Commercial |
$2.87
|
| Rate for Payer: PHP All Commercial |
$2.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.49
|
| Rate for Payer: Sagamore Health Network All Products |
$2.96
|
| Rate for Payer: Signature Care EPO |
$3.18
|
| Rate for Payer: Signature Care PPO |
$3.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.25
|
| Rate for Payer: United Healthcare Commercial |
$3.02
|
| Rate for Payer: United Healthcare Medicare |
$1.26
|
|
|
FLUCICLOVINE F18 10 MCI (370 MBQ) IV SOLN
|
Facility
|
OP
|
$17,304.00
|
|
|
Service Code
|
HCPCS A9588
|
| Hospital Charge Code |
182304
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5,710.32 |
| Max. Negotiated Rate |
$16,092.72 |
| Rate for Payer: Aetna Commercial |
$14,604.58
|
| Rate for Payer: Aetna Medicare |
$5,710.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,710.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9,937.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10,816.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6,566.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6,281.35
|
| Rate for Payer: Cash Price |
$10,728.48
|
| Rate for Payer: Centivo All Commercial |
$8,825.04
|
| Rate for Payer: Cigna All Commercial |
$14,933.35
|
| Rate for Payer: CORVEL All Commercial |
$16,092.72
|
| Rate for Payer: Coventry All Commercial |
$15,227.52
|
| Rate for Payer: Encore All Commercial |
$15,928.33
|
| Rate for Payer: Frontpath All Commercial |
$15,919.68
|
| Rate for Payer: Humana ChoiceCare |
$14,945.46
|
| Rate for Payer: Humana Medicare |
$8,825.04
|
| Rate for Payer: Lucent All Commercial |
$8,825.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15,573.60
|
| Rate for Payer: PHCS All Commercial |
$12,978.00
|
| Rate for Payer: PHP All Commercial |
$13,123.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,748.56
|
| Rate for Payer: Sagamore Health Network All Products |
$13,358.69
|
| Rate for Payer: Signature Care EPO |
$14,362.32
|
| Rate for Payer: Signature Care PPO |
$15,227.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$14,708.40
|
| Rate for Payer: United Healthcare Commercial |
$13,635.55
|
| Rate for Payer: United Healthcare Medicare |
$5,710.32
|
|
|
FLUCICLOVINE F18 10 MCI (370 MBQ) IV SOLN
|
Facility
|
IP
|
$17,304.00
|
|
|
Service Code
|
HCPCS A9588
|
| Hospital Charge Code |
182304
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$12,978.00 |
| Max. Negotiated Rate |
$16,092.72 |
| Rate for Payer: Aetna Commercial |
$14,950.66
|
| Rate for Payer: Cash Price |
$10,728.48
|
| Rate for Payer: Cigna All Commercial |
$14,933.35
|
| Rate for Payer: CORVEL All Commercial |
$16,092.72
|
| Rate for Payer: Coventry All Commercial |
$15,227.52
|
| Rate for Payer: Encore All Commercial |
$15,928.33
|
| Rate for Payer: Frontpath All Commercial |
$15,919.68
|
| Rate for Payer: Humana ChoiceCare |
$14,945.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15,573.60
|
| Rate for Payer: PHCS All Commercial |
$12,978.00
|
| Rate for Payer: PHP All Commercial |
$13,123.35
|
| Rate for Payer: Sagamore Health Network All Products |
$13,358.69
|
| Rate for Payer: Signature Care EPO |
$14,362.32
|
| Rate for Payer: Signature Care PPO |
$15,227.52
|
| Rate for Payer: United Healthcare Commercial |
$13,635.55
|
|
|
FLUCONAZOLE 100 MG ORAL TAB
|
Facility
|
IP
|
$7.88
|
|
|
Service Code
|
NDC 00904650061
|
| Hospital Charge Code |
10044
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.91 |
| Max. Negotiated Rate |
$7.33 |
| Rate for Payer: Aetna Commercial |
$6.81
|
| Rate for Payer: Cash Price |
$4.89
|
| Rate for Payer: Cigna All Commercial |
$6.80
|
| Rate for Payer: CORVEL All Commercial |
$7.33
|
| Rate for Payer: Coventry All Commercial |
$6.94
|
| Rate for Payer: Encore All Commercial |
$7.26
|
| Rate for Payer: Frontpath All Commercial |
$7.25
|
| Rate for Payer: Humana ChoiceCare |
$6.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.09
|
| Rate for Payer: PHCS All Commercial |
$5.91
|
| Rate for Payer: PHP All Commercial |
$5.98
|
| Rate for Payer: Sagamore Health Network All Products |
$6.08
|
| Rate for Payer: Signature Care EPO |
$6.54
|
| Rate for Payer: Signature Care PPO |
$6.94
|
| Rate for Payer: United Healthcare Commercial |
$6.21
|
|
|
FLUCONAZOLE 100 MG ORAL TAB
|
Facility
|
OP
|
$7.88
|
|
|
Service Code
|
NDC 00904650061
|
| Hospital Charge Code |
10044
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$7.33 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Medicare |
$2.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.86
|
| Rate for Payer: Cash Price |
$4.89
|
| Rate for Payer: Centivo All Commercial |
$4.02
|
| Rate for Payer: Cigna All Commercial |
$6.80
|
| Rate for Payer: CORVEL All Commercial |
$7.33
|
| Rate for Payer: Coventry All Commercial |
$6.94
|
| Rate for Payer: Encore All Commercial |
$7.26
|
| Rate for Payer: Frontpath All Commercial |
$7.25
|
| Rate for Payer: Humana ChoiceCare |
$6.81
|
| Rate for Payer: Humana Medicare |
$4.02
|
| Rate for Payer: Lucent All Commercial |
$4.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.09
|
| Rate for Payer: PHCS All Commercial |
$5.91
|
| Rate for Payer: PHP All Commercial |
$5.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.07
|
| Rate for Payer: Sagamore Health Network All Products |
$6.08
|
| Rate for Payer: Signature Care EPO |
$6.54
|
| Rate for Payer: Signature Care PPO |
$6.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.70
|
| Rate for Payer: United Healthcare Commercial |
$6.21
|
| Rate for Payer: United Healthcare Medicare |
$2.60
|
|
|
FLUCONAZOLE 150 MG ORAL TAB
|
Facility
|
OP
|
$17.94
|
|
|
Service Code
|
NDC 68462011944
|
| Hospital Charge Code |
13577
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$16.69 |
| Rate for Payer: Aetna Commercial |
$15.14
|
| Rate for Payer: Aetna Medicare |
$5.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.51
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Centivo All Commercial |
$9.15
|
| Rate for Payer: Cigna All Commercial |
$15.48
|
| Rate for Payer: CORVEL All Commercial |
$16.69
|
| Rate for Payer: Coventry All Commercial |
$15.79
|
| Rate for Payer: Encore All Commercial |
$16.51
|
| Rate for Payer: Frontpath All Commercial |
$16.51
|
| Rate for Payer: Humana ChoiceCare |
$15.50
|
| Rate for Payer: Humana Medicare |
$9.15
|
| Rate for Payer: Lucent All Commercial |
$9.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.15
|
| Rate for Payer: PHCS All Commercial |
$13.46
|
| Rate for Payer: PHP All Commercial |
$13.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.00
|
| Rate for Payer: Sagamore Health Network All Products |
$13.85
|
| Rate for Payer: Signature Care EPO |
$14.89
|
| Rate for Payer: Signature Care PPO |
$15.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.25
|
| Rate for Payer: United Healthcare Commercial |
$14.14
|
| Rate for Payer: United Healthcare Medicare |
$5.92
|
|
|
FLUCONAZOLE 150 MG ORAL TAB
|
Facility
|
IP
|
$17.94
|
|
|
Service Code
|
NDC 68462011944
|
| Hospital Charge Code |
13577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.46 |
| Max. Negotiated Rate |
$16.69 |
| Rate for Payer: Aetna Commercial |
$15.50
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Cigna All Commercial |
$15.48
|
| Rate for Payer: CORVEL All Commercial |
$16.69
|
| Rate for Payer: Coventry All Commercial |
$15.79
|
| Rate for Payer: Encore All Commercial |
$16.51
|
| Rate for Payer: Frontpath All Commercial |
$16.51
|
| Rate for Payer: Humana ChoiceCare |
$15.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.15
|
| Rate for Payer: PHCS All Commercial |
$13.46
|
| Rate for Payer: PHP All Commercial |
$13.61
|
| Rate for Payer: Sagamore Health Network All Products |
$13.85
|
| Rate for Payer: Signature Care EPO |
$14.89
|
| Rate for Payer: Signature Care PPO |
$15.79
|
| Rate for Payer: United Healthcare Commercial |
$14.14
|
|
|
FLUCONAZOLE IN NACL (ISO-OSM) 200 MG/100 ML IV PGBK
|
Facility
|
OP
|
$58.10
|
|
|
Service Code
|
HCPCS J1450
|
| Hospital Charge Code |
10049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.17 |
| Max. Negotiated Rate |
$54.03 |
| Rate for Payer: Aetna Commercial |
$49.04
|
| Rate for Payer: Aetna Medicare |
$19.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$33.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$36.32
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$22.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$21.09
|
| Rate for Payer: Cash Price |
$36.02
|
| Rate for Payer: Centivo All Commercial |
$29.63
|
| Rate for Payer: Cigna All Commercial |
$50.14
|
| Rate for Payer: CORVEL All Commercial |
$54.03
|
| Rate for Payer: Coventry All Commercial |
$51.13
|
| Rate for Payer: Encore All Commercial |
$53.48
|
| Rate for Payer: Frontpath All Commercial |
$53.45
|
| Rate for Payer: Humana ChoiceCare |
$50.18
|
| Rate for Payer: Humana Medicare |
$29.63
|
| Rate for Payer: Lucent All Commercial |
$29.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$52.29
|
| Rate for Payer: PHCS All Commercial |
$43.58
|
| Rate for Payer: PHP All Commercial |
$44.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.66
|
| Rate for Payer: Sagamore Health Network All Products |
$44.85
|
| Rate for Payer: Signature Care EPO |
$48.22
|
| Rate for Payer: Signature Care PPO |
$51.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$49.38
|
| Rate for Payer: United Healthcare Commercial |
$45.78
|
| Rate for Payer: United Healthcare Medicare |
$19.17
|
|
|
FLUCONAZOLE IN NACL (ISO-OSM) 200 MG/100 ML IV PGBK
|
Facility
|
IP
|
$58.10
|
|
|
Service Code
|
HCPCS J1450
|
| Hospital Charge Code |
10049
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.58 |
| Max. Negotiated Rate |
$54.03 |
| Rate for Payer: Aetna Commercial |
$50.20
|
| Rate for Payer: Cash Price |
$36.02
|
| Rate for Payer: Cigna All Commercial |
$50.14
|
| Rate for Payer: CORVEL All Commercial |
$54.03
|
| Rate for Payer: Coventry All Commercial |
$51.13
|
| Rate for Payer: Encore All Commercial |
$53.48
|
| Rate for Payer: Frontpath All Commercial |
$53.45
|
| Rate for Payer: Humana ChoiceCare |
$50.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$52.29
|
| Rate for Payer: PHCS All Commercial |
$43.58
|
| Rate for Payer: PHP All Commercial |
$44.06
|
| Rate for Payer: Sagamore Health Network All Products |
$44.85
|
| Rate for Payer: Signature Care EPO |
$48.22
|
| Rate for Payer: Signature Care PPO |
$51.13
|
| Rate for Payer: United Healthcare Commercial |
$45.78
|
|
|
FLUDEOXYGLUCOSE F-18 20 MCI TO 500 MCI/ML IV SOLN
|
Facility
|
IP
|
$759.90
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
166388
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$569.92 |
| Max. Negotiated Rate |
$706.71 |
| Rate for Payer: Aetna Commercial |
$656.55
|
| Rate for Payer: Cash Price |
$471.14
|
| Rate for Payer: Cigna All Commercial |
$655.79
|
| Rate for Payer: CORVEL All Commercial |
$706.71
|
| Rate for Payer: Coventry All Commercial |
$668.71
|
| Rate for Payer: Encore All Commercial |
$699.49
|
| Rate for Payer: Frontpath All Commercial |
$699.11
|
| Rate for Payer: Humana ChoiceCare |
$656.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$683.91
|
| Rate for Payer: PHCS All Commercial |
$569.92
|
| Rate for Payer: PHP All Commercial |
$576.31
|
| Rate for Payer: Sagamore Health Network All Products |
$586.64
|
| Rate for Payer: Signature Care EPO |
$630.72
|
| Rate for Payer: Signature Care PPO |
$668.71
|
| Rate for Payer: United Healthcare Commercial |
$598.80
|
|
|
FLUDEOXYGLUCOSE F-18 20 MCI TO 500 MCI/ML IV SOLN
|
Facility
|
OP
|
$759.90
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
166388
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$250.77 |
| Max. Negotiated Rate |
$706.71 |
| Rate for Payer: Aetna Commercial |
$641.36
|
| Rate for Payer: Aetna Medicare |
$250.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$250.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$436.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$475.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$288.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$275.84
|
| Rate for Payer: Cash Price |
$471.14
|
| Rate for Payer: Centivo All Commercial |
$387.55
|
| Rate for Payer: Cigna All Commercial |
$655.79
|
| Rate for Payer: CORVEL All Commercial |
$706.71
|
| Rate for Payer: Coventry All Commercial |
$668.71
|
| Rate for Payer: Encore All Commercial |
$699.49
|
| Rate for Payer: Frontpath All Commercial |
$699.11
|
| Rate for Payer: Humana ChoiceCare |
$656.33
|
| Rate for Payer: Humana Medicare |
$387.55
|
| Rate for Payer: Lucent All Commercial |
$387.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$683.91
|
| Rate for Payer: PHCS All Commercial |
$569.92
|
| Rate for Payer: PHP All Commercial |
$576.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$296.36
|
| Rate for Payer: Sagamore Health Network All Products |
$586.64
|
| Rate for Payer: Signature Care EPO |
$630.72
|
| Rate for Payer: Signature Care PPO |
$668.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$645.92
|
| Rate for Payer: United Healthcare Commercial |
$598.80
|
| Rate for Payer: United Healthcare Medicare |
$250.77
|
|
|
FLUDROCORTISONE 0.1 MG ORAL TAB
|
Facility
|
OP
|
$2.91
|
|
|
Service Code
|
NDC 50268033015
|
| Hospital Charge Code |
10054
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna Commercial |
$2.45
|
| Rate for Payer: Aetna Medicare |
$0.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.82
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.05
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Centivo All Commercial |
$1.48
|
| Rate for Payer: Cigna All Commercial |
$2.51
|
| Rate for Payer: CORVEL All Commercial |
$2.70
|
| Rate for Payer: Coventry All Commercial |
$2.56
|
| Rate for Payer: Encore All Commercial |
$2.67
|
| Rate for Payer: Frontpath All Commercial |
$2.67
|
| Rate for Payer: Humana ChoiceCare |
$2.51
|
| Rate for Payer: Humana Medicare |
$1.48
|
| Rate for Payer: Lucent All Commercial |
$1.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.61
|
| Rate for Payer: PHCS All Commercial |
$2.18
|
| Rate for Payer: PHP All Commercial |
$2.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.13
|
| Rate for Payer: Sagamore Health Network All Products |
$2.24
|
| Rate for Payer: Signature Care EPO |
$2.41
|
| Rate for Payer: Signature Care PPO |
$2.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.47
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
| Rate for Payer: United Healthcare Medicare |
$0.96
|
|
|
FLUDROCORTISONE 0.1 MG ORAL TAB
|
Facility
|
IP
|
$2.91
|
|
|
Service Code
|
NDC 50268033015
|
| Hospital Charge Code |
10054
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna Commercial |
$2.51
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna All Commercial |
$2.51
|
| Rate for Payer: CORVEL All Commercial |
$2.70
|
| Rate for Payer: Coventry All Commercial |
$2.56
|
| Rate for Payer: Encore All Commercial |
$2.67
|
| Rate for Payer: Frontpath All Commercial |
$2.67
|
| Rate for Payer: Humana ChoiceCare |
$2.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.61
|
| Rate for Payer: PHCS All Commercial |
$2.18
|
| Rate for Payer: PHP All Commercial |
$2.20
|
| Rate for Payer: Sagamore Health Network All Products |
$2.24
|
| Rate for Payer: Signature Care EPO |
$2.41
|
| Rate for Payer: Signature Care PPO |
$2.56
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
|
|
FLUMAZENIL 0.1 MG/ML IV SOLN
|
Facility
|
IP
|
$29.54
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.16 |
| Max. Negotiated Rate |
$27.47 |
| Rate for Payer: Aetna Commercial |
$25.52
|
| Rate for Payer: Cash Price |
$18.31
|
| Rate for Payer: Cigna All Commercial |
$25.49
|
| Rate for Payer: CORVEL All Commercial |
$27.47
|
| Rate for Payer: Coventry All Commercial |
$26.00
|
| Rate for Payer: Encore All Commercial |
$27.19
|
| Rate for Payer: Frontpath All Commercial |
$27.18
|
| Rate for Payer: Humana ChoiceCare |
$25.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.59
|
| Rate for Payer: PHCS All Commercial |
$22.16
|
| Rate for Payer: PHP All Commercial |
$22.40
|
| Rate for Payer: Sagamore Health Network All Products |
$22.80
|
| Rate for Payer: Signature Care EPO |
$24.52
|
| Rate for Payer: Signature Care PPO |
$26.00
|
| Rate for Payer: United Healthcare Commercial |
$23.28
|
|
|
FLUMAZENIL 0.1 MG/ML IV SOLN
|
Facility
|
OP
|
$29.54
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
10055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$27.47 |
| Rate for Payer: Aetna Commercial |
$24.93
|
| Rate for Payer: Aetna Medicare |
$9.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.47
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.72
|
| Rate for Payer: Cash Price |
$18.31
|
| Rate for Payer: Centivo All Commercial |
$15.07
|
| Rate for Payer: Cigna All Commercial |
$25.49
|
| Rate for Payer: CORVEL All Commercial |
$27.47
|
| Rate for Payer: Coventry All Commercial |
$26.00
|
| Rate for Payer: Encore All Commercial |
$27.19
|
| Rate for Payer: Frontpath All Commercial |
$27.18
|
| Rate for Payer: Humana ChoiceCare |
$25.51
|
| Rate for Payer: Humana Medicare |
$15.07
|
| Rate for Payer: Lucent All Commercial |
$15.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.59
|
| Rate for Payer: PHCS All Commercial |
$22.16
|
| Rate for Payer: PHP All Commercial |
$22.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.52
|
| Rate for Payer: Sagamore Health Network All Products |
$22.80
|
| Rate for Payer: Signature Care EPO |
$24.52
|
| Rate for Payer: Signature Care PPO |
$26.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25.11
|
| Rate for Payer: United Healthcare Commercial |
$23.28
|
| Rate for Payer: United Healthcare Medicare |
$9.75
|
|
|
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 |
$1.11
|
| 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
|
|
|
FLUORESCEIN 1 MG OPHT STRP
|
Facility
|
OP
|
$1.79
|
|
|
Service Code
|
NDC 17238090011
|
| Hospital Charge Code |
27663
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$1.51
|
| Rate for Payer: Aetna Medicare |
$0.59
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.12
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Centivo All Commercial |
$0.91
|
| 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 |
$0.91
|
| Rate for Payer: Lucent All Commercial |
$0.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.61
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| 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 |
$0.59
|
|
|
FLUOROESTRADIOL F-18 148 MBQ/ML TO 3,700 MBQ/ML IV SOLN
|
Facility
|
IP
|
$17,156.74
|
|
|
Service Code
|
HCPCS A9591
|
| Hospital Charge Code |
192951
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$12,867.56 |
| Max. Negotiated Rate |
$15,955.77 |
| Rate for Payer: Aetna Commercial |
$14,823.42
|
| Rate for Payer: Cash Price |
$10,637.18
|
| Rate for Payer: Cigna All Commercial |
$14,806.27
|
| Rate for Payer: CORVEL All Commercial |
$15,955.77
|
| Rate for Payer: Coventry All Commercial |
$15,097.93
|
| Rate for Payer: Encore All Commercial |
$15,792.78
|
| Rate for Payer: Frontpath All Commercial |
$15,784.20
|
| Rate for Payer: Humana ChoiceCare |
$14,818.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15,441.07
|
| Rate for Payer: PHCS All Commercial |
$12,867.56
|
| Rate for Payer: PHP All Commercial |
$13,011.67
|
| Rate for Payer: Sagamore Health Network All Products |
$13,245.00
|
| Rate for Payer: Signature Care EPO |
$14,240.09
|
| Rate for Payer: Signature Care PPO |
$15,097.93
|
| Rate for Payer: United Healthcare Commercial |
$13,519.51
|
|
