|
FLUOROESTRADIOL F-18 148 MBQ/ML TO 3,700 MBQ/ML IV SOLN
|
Facility
OP
|
$17,156.74
|
|
|
Service Code
|
HCPCS A9591
|
| Hospital Charge Code |
192951
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$5,661.72 |
| Max. Negotiated Rate |
$15,955.77 |
| Rate for Payer: Aetna Commercial |
$14,480.29
|
| Rate for Payer: Aetna Medicare |
$5,661.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,661.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9,853.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10,724.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6,510.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6,227.90
|
| Rate for Payer: Cash Price |
$10,637.18
|
| Rate for Payer: Centivo All Commercial |
$8,749.94
|
| 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: Humana Medicare |
$8,749.94
|
| Rate for Payer: Lucent All Commercial |
$8,749.94
|
| 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: Plain Church Group Ministry All Commercial |
$6,691.13
|
| 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: Three Rivers Preferred All Commercial |
$14,583.23
|
| Rate for Payer: United Healthcare Commercial |
$13,519.51
|
| Rate for Payer: United Healthcare Medicare |
$5,661.72
|
|
|
FLUOROMETHOLONE 0.25 % OPHT DRPS
|
Facility
OP
|
$351.45
|
|
|
Service Code
|
NDC 11980022805
|
| Hospital Charge Code |
19722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$326.85 |
| Rate for Payer: Aetna Commercial |
$296.62
|
| Rate for Payer: Aetna Medicare |
$115.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$115.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$201.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$219.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$133.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$127.58
|
| Rate for Payer: Cash Price |
$217.90
|
| Rate for Payer: Cash Price |
$217.90
|
| Rate for Payer: Centivo All Commercial |
$179.24
|
| Rate for Payer: Cigna All Commercial |
$303.30
|
| Rate for Payer: CORVEL All Commercial |
$326.85
|
| Rate for Payer: Coventry All Commercial |
$309.28
|
| Rate for Payer: Encore All Commercial |
$323.51
|
| Rate for Payer: Frontpath All Commercial |
$323.33
|
| Rate for Payer: Humana ChoiceCare |
$303.55
|
| Rate for Payer: Humana Medicare |
$179.24
|
| Rate for Payer: Lucent All Commercial |
$179.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$316.30
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$263.59
|
| Rate for Payer: PHP All Commercial |
$266.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$137.07
|
| Rate for Payer: Sagamore Health Network All Products |
$271.32
|
| Rate for Payer: Signature Care EPO |
$291.70
|
| Rate for Payer: Signature Care PPO |
$309.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$298.73
|
| Rate for Payer: United Healthcare Commercial |
$276.94
|
| Rate for Payer: United Healthcare Medicare |
$115.98
|
|
|
FLUOROMETHOLONE 0.25 % OPHT DRPS
|
Facility
IP
|
$351.45
|
|
|
Service Code
|
NDC 11980022805
|
| Hospital Charge Code |
19722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$263.59 |
| Max. Negotiated Rate |
$326.85 |
| Rate for Payer: Aetna Commercial |
$303.65
|
| Rate for Payer: Cash Price |
$217.90
|
| Rate for Payer: Cigna All Commercial |
$303.30
|
| Rate for Payer: CORVEL All Commercial |
$326.85
|
| Rate for Payer: Coventry All Commercial |
$309.28
|
| Rate for Payer: Encore All Commercial |
$323.51
|
| Rate for Payer: Frontpath All Commercial |
$323.33
|
| Rate for Payer: Humana ChoiceCare |
$303.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$316.30
|
| Rate for Payer: PHCS All Commercial |
$263.59
|
| Rate for Payer: PHP All Commercial |
$266.54
|
| Rate for Payer: Sagamore Health Network All Products |
$271.32
|
| Rate for Payer: Signature Care EPO |
$291.70
|
| Rate for Payer: Signature Care PPO |
$309.28
|
| Rate for Payer: United Healthcare Commercial |
$276.94
|
|
|
FLUOXETINE 10 MG ORAL CAP
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 65862019201
|
| Hospital Charge Code |
10069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
FLUOXETINE 10 MG ORAL CAP
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 65862019201
|
| Hospital Charge Code |
10069
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
FLUOXETINE 20 MG ORAL CAP
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904734661
|
| Hospital Charge Code |
10070
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
FLUOXETINE 20 MG ORAL CAP
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904734661
|
| Hospital Charge Code |
10070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| 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
|
|
|
FLUPHENAZINE HCL 5 MG ORAL TAB
|
Facility
OP
|
$30.94
|
|
|
Service Code
|
NDC 00527179001
|
| Hospital Charge Code |
3221
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$28.77 |
| Rate for Payer: Aetna Commercial |
$26.11
|
| Rate for Payer: Aetna Medicare |
$10.21
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$17.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.34
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.23
|
| Rate for Payer: Cash Price |
$19.18
|
| Rate for Payer: Centivo All Commercial |
$15.78
|
| Rate for Payer: Cigna All Commercial |
$26.70
|
| Rate for Payer: CORVEL All Commercial |
$28.77
|
| Rate for Payer: Coventry All Commercial |
$27.23
|
| Rate for Payer: Encore All Commercial |
$28.48
|
| Rate for Payer: Frontpath All Commercial |
$28.46
|
| Rate for Payer: Humana ChoiceCare |
$26.72
|
| Rate for Payer: Humana Medicare |
$15.78
|
| Rate for Payer: Lucent All Commercial |
$15.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.85
|
| Rate for Payer: PHCS All Commercial |
$23.20
|
| Rate for Payer: PHP All Commercial |
$23.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.07
|
| Rate for Payer: Sagamore Health Network All Products |
$23.89
|
| Rate for Payer: Signature Care EPO |
$25.68
|
| Rate for Payer: Signature Care PPO |
$27.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.30
|
| Rate for Payer: United Healthcare Commercial |
$24.38
|
| Rate for Payer: United Healthcare Medicare |
$10.21
|
|
|
FLUPHENAZINE HCL 5 MG ORAL TAB
|
Facility
IP
|
$30.94
|
|
|
Service Code
|
NDC 00527179001
|
| Hospital Charge Code |
3221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.20 |
| Max. Negotiated Rate |
$28.77 |
| Rate for Payer: Aetna Commercial |
$26.73
|
| Rate for Payer: Cash Price |
$19.18
|
| Rate for Payer: Cigna All Commercial |
$26.70
|
| Rate for Payer: CORVEL All Commercial |
$28.77
|
| Rate for Payer: Coventry All Commercial |
$27.23
|
| Rate for Payer: Encore All Commercial |
$28.48
|
| Rate for Payer: Frontpath All Commercial |
$28.46
|
| Rate for Payer: Humana ChoiceCare |
$26.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.85
|
| Rate for Payer: PHCS All Commercial |
$23.20
|
| Rate for Payer: PHP All Commercial |
$23.46
|
| Rate for Payer: Sagamore Health Network All Products |
$23.89
|
| Rate for Payer: Signature Care EPO |
$25.68
|
| Rate for Payer: Signature Care PPO |
$27.23
|
| Rate for Payer: United Healthcare Commercial |
$24.38
|
|
|
FLURBIPROFEN SODIUM 0.03 % OPHT DROP
|
Facility
OP
|
$243.39
|
|
|
Service Code
|
NDC 69292072225
|
| Hospital Charge Code |
10080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$226.35 |
| Rate for Payer: Aetna Commercial |
$205.42
|
| Rate for Payer: Aetna Medicare |
$80.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$80.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$139.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$152.14
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$92.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$88.35
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Centivo All Commercial |
$124.13
|
| Rate for Payer: Cigna All Commercial |
$210.05
|
| Rate for Payer: CORVEL All Commercial |
$226.35
|
| Rate for Payer: Coventry All Commercial |
$214.18
|
| Rate for Payer: Encore All Commercial |
$224.04
|
| Rate for Payer: Frontpath All Commercial |
$223.92
|
| Rate for Payer: Humana ChoiceCare |
$210.22
|
| Rate for Payer: Humana Medicare |
$124.13
|
| Rate for Payer: Lucent All Commercial |
$124.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$219.05
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$182.54
|
| Rate for Payer: PHP All Commercial |
$184.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$94.92
|
| Rate for Payer: Sagamore Health Network All Products |
$187.90
|
| Rate for Payer: Signature Care EPO |
$202.01
|
| Rate for Payer: Signature Care PPO |
$214.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$206.88
|
| Rate for Payer: United Healthcare Commercial |
$191.79
|
| Rate for Payer: United Healthcare Medicare |
$80.32
|
|
|
FLURBIPROFEN SODIUM 0.03 % OPHT DROP
|
Facility
IP
|
$243.39
|
|
|
Service Code
|
NDC 69292072225
|
| Hospital Charge Code |
10080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$182.54 |
| Max. Negotiated Rate |
$226.35 |
| Rate for Payer: Aetna Commercial |
$210.29
|
| Rate for Payer: Cash Price |
$150.90
|
| Rate for Payer: Cigna All Commercial |
$210.05
|
| Rate for Payer: CORVEL All Commercial |
$226.35
|
| Rate for Payer: Coventry All Commercial |
$214.18
|
| Rate for Payer: Encore All Commercial |
$224.04
|
| Rate for Payer: Frontpath All Commercial |
$223.92
|
| Rate for Payer: Humana ChoiceCare |
$210.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$219.05
|
| Rate for Payer: PHCS All Commercial |
$182.54
|
| Rate for Payer: PHP All Commercial |
$184.59
|
| Rate for Payer: Sagamore Health Network All Products |
$187.90
|
| Rate for Payer: Signature Care EPO |
$202.01
|
| Rate for Payer: Signature Care PPO |
$214.18
|
| Rate for Payer: United Healthcare Commercial |
$191.79
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASL SPSN
|
Facility
OP
|
$41.44
|
|
|
Service Code
|
NDC 60505082901
|
| Hospital Charge Code |
70536
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.68 |
| Max. Negotiated Rate |
$38.54 |
| Rate for Payer: Aetna Commercial |
$34.98
|
| Rate for Payer: Aetna Medicare |
$13.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$23.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$25.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.04
|
| Rate for Payer: Cash Price |
$25.69
|
| Rate for Payer: Centivo All Commercial |
$21.13
|
| Rate for Payer: Cigna All Commercial |
$35.76
|
| Rate for Payer: CORVEL All Commercial |
$38.54
|
| Rate for Payer: Coventry All Commercial |
$36.47
|
| Rate for Payer: Encore All Commercial |
$38.15
|
| Rate for Payer: Frontpath All Commercial |
$38.12
|
| Rate for Payer: Humana ChoiceCare |
$35.79
|
| Rate for Payer: Humana Medicare |
$21.13
|
| Rate for Payer: Lucent All Commercial |
$21.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.30
|
| Rate for Payer: PHCS All Commercial |
$31.08
|
| Rate for Payer: PHP All Commercial |
$31.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.16
|
| Rate for Payer: Sagamore Health Network All Products |
$31.99
|
| Rate for Payer: Signature Care EPO |
$34.40
|
| Rate for Payer: Signature Care PPO |
$36.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.22
|
| Rate for Payer: United Healthcare Commercial |
$32.65
|
| Rate for Payer: United Healthcare Medicare |
$13.68
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASL SPSN
|
Facility
IP
|
$41.44
|
|
|
Service Code
|
NDC 60505082901
|
| Hospital Charge Code |
70536
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.08 |
| Max. Negotiated Rate |
$38.54 |
| Rate for Payer: Aetna Commercial |
$35.80
|
| Rate for Payer: Cash Price |
$25.69
|
| Rate for Payer: Cigna All Commercial |
$35.76
|
| Rate for Payer: CORVEL All Commercial |
$38.54
|
| Rate for Payer: Coventry All Commercial |
$36.47
|
| Rate for Payer: Encore All Commercial |
$38.15
|
| Rate for Payer: Frontpath All Commercial |
$38.12
|
| Rate for Payer: Humana ChoiceCare |
$35.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.30
|
| Rate for Payer: PHCS All Commercial |
$31.08
|
| Rate for Payer: PHP All Commercial |
$31.43
|
| Rate for Payer: Sagamore Health Network All Products |
$31.99
|
| Rate for Payer: Signature Care EPO |
$34.40
|
| Rate for Payer: Signature Care PPO |
$36.47
|
| Rate for Payer: United Healthcare Commercial |
$32.65
|
|
|
FLU VACC TS2024-25(65YR UP)-PF 180 MCG/0.5 ML IM SYRG
|
Facility
OP
|
$326.89
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
205593
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.87 |
| Max. Negotiated Rate |
$304.01 |
| Rate for Payer: Aetna Commercial |
$275.90
|
| Rate for Payer: Aetna Medicare |
$107.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$107.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$187.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$204.34
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$124.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$118.66
|
| Rate for Payer: Cash Price |
$202.67
|
| Rate for Payer: Centivo All Commercial |
$166.71
|
| Rate for Payer: Cigna All Commercial |
$282.11
|
| Rate for Payer: CORVEL All Commercial |
$304.01
|
| Rate for Payer: Coventry All Commercial |
$287.66
|
| Rate for Payer: Encore All Commercial |
$300.90
|
| Rate for Payer: Frontpath All Commercial |
$300.74
|
| Rate for Payer: Humana ChoiceCare |
$282.33
|
| Rate for Payer: Humana Medicare |
$166.71
|
| Rate for Payer: Lucent All Commercial |
$166.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$294.20
|
| Rate for Payer: PHCS All Commercial |
$245.17
|
| Rate for Payer: PHP All Commercial |
$247.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$127.49
|
| Rate for Payer: Sagamore Health Network All Products |
$252.36
|
| Rate for Payer: Signature Care EPO |
$271.32
|
| Rate for Payer: Signature Care PPO |
$287.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$277.86
|
| Rate for Payer: United Healthcare Commercial |
$257.59
|
| Rate for Payer: United Healthcare Medicare |
$107.87
|
|
|
FLU VACC TS2024-25(65YR UP)-PF 180 MCG/0.5 ML IM SYRG
|
Facility
IP
|
$326.89
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
205593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$245.17 |
| Max. Negotiated Rate |
$304.01 |
| Rate for Payer: Aetna Commercial |
$282.43
|
| Rate for Payer: Cash Price |
$202.67
|
| Rate for Payer: Cigna All Commercial |
$282.11
|
| Rate for Payer: CORVEL All Commercial |
$304.01
|
| Rate for Payer: Coventry All Commercial |
$287.66
|
| Rate for Payer: Encore All Commercial |
$300.90
|
| Rate for Payer: Frontpath All Commercial |
$300.74
|
| Rate for Payer: Humana ChoiceCare |
$282.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$294.20
|
| Rate for Payer: PHCS All Commercial |
$245.17
|
| Rate for Payer: PHP All Commercial |
$247.91
|
| Rate for Payer: Sagamore Health Network All Products |
$252.36
|
| Rate for Payer: Signature Care EPO |
$271.32
|
| Rate for Payer: Signature Care PPO |
$287.66
|
| Rate for Payer: United Healthcare Commercial |
$257.59
|
|
|
FLU VACC TS2024-25 6MOS UP(PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG
|
Facility
IP
|
$132.86
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
205592
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.64 |
| Max. Negotiated Rate |
$123.56 |
| Rate for Payer: Aetna Commercial |
$114.79
|
| Rate for Payer: Cash Price |
$82.37
|
| Rate for Payer: Cigna All Commercial |
$114.66
|
| Rate for Payer: CORVEL All Commercial |
$123.56
|
| Rate for Payer: Coventry All Commercial |
$116.92
|
| Rate for Payer: Encore All Commercial |
$122.30
|
| Rate for Payer: Frontpath All Commercial |
$122.23
|
| Rate for Payer: Humana ChoiceCare |
$114.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$119.57
|
| Rate for Payer: PHCS All Commercial |
$99.64
|
| Rate for Payer: PHP All Commercial |
$100.76
|
| Rate for Payer: Sagamore Health Network All Products |
$102.57
|
| Rate for Payer: Signature Care EPO |
$110.27
|
| Rate for Payer: Signature Care PPO |
$116.92
|
| Rate for Payer: United Healthcare Commercial |
$104.69
|
|
|
FLU VACC TS2024-25 6MOS UP(PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG
|
Facility
OP
|
$132.86
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
205592
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.84 |
| Max. Negotiated Rate |
$123.56 |
| Rate for Payer: Aetna Commercial |
$112.13
|
| Rate for Payer: Aetna Medicare |
$43.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$43.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$76.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$83.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$50.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$48.23
|
| Rate for Payer: Cash Price |
$82.37
|
| Rate for Payer: Centivo All Commercial |
$67.76
|
| Rate for Payer: Cigna All Commercial |
$114.66
|
| Rate for Payer: CORVEL All Commercial |
$123.56
|
| Rate for Payer: Coventry All Commercial |
$116.92
|
| Rate for Payer: Encore All Commercial |
$122.30
|
| Rate for Payer: Frontpath All Commercial |
$122.23
|
| Rate for Payer: Humana ChoiceCare |
$114.75
|
| Rate for Payer: Humana Medicare |
$67.76
|
| Rate for Payer: Lucent All Commercial |
$67.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$119.57
|
| Rate for Payer: PHCS All Commercial |
$99.64
|
| Rate for Payer: PHP All Commercial |
$100.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$51.82
|
| Rate for Payer: Sagamore Health Network All Products |
$102.57
|
| Rate for Payer: Signature Care EPO |
$110.27
|
| Rate for Payer: Signature Care PPO |
$116.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$112.93
|
| Rate for Payer: United Healthcare Commercial |
$104.69
|
| Rate for Payer: United Healthcare Medicare |
$43.84
|
|
|
FOLIC ACID 1 MG ORAL TAB
|
Facility
OP
|
$1.30
|
|
|
Service Code
|
NDC 11534016501
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna Commercial |
$1.10
|
| Rate for Payer: Aetna Medicare |
$0.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.47
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Centivo All Commercial |
$0.66
|
| Rate for Payer: Cigna All Commercial |
$1.12
|
| Rate for Payer: CORVEL All Commercial |
$1.21
|
| Rate for Payer: Coventry All Commercial |
$1.15
|
| Rate for Payer: Encore All Commercial |
$1.20
|
| Rate for Payer: Frontpath All Commercial |
$1.20
|
| Rate for Payer: Humana ChoiceCare |
$1.12
|
| Rate for Payer: Humana Medicare |
$0.66
|
| Rate for Payer: Lucent All Commercial |
$0.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.17
|
| Rate for Payer: PHCS All Commercial |
$0.98
|
| Rate for Payer: PHP All Commercial |
$0.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.51
|
| Rate for Payer: Sagamore Health Network All Products |
$1.01
|
| Rate for Payer: Signature Care EPO |
$1.08
|
| Rate for Payer: Signature Care PPO |
$1.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.11
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
| Rate for Payer: United Healthcare Medicare |
$0.43
|
|
|
FOLIC ACID 1 MG ORAL TAB
|
Facility
IP
|
$1.30
|
|
|
Service Code
|
NDC 11534016501
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna Commercial |
$1.12
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: Cigna All Commercial |
$1.12
|
| Rate for Payer: CORVEL All Commercial |
$1.21
|
| Rate for Payer: Coventry All Commercial |
$1.15
|
| Rate for Payer: Encore All Commercial |
$1.20
|
| Rate for Payer: Frontpath All Commercial |
$1.20
|
| Rate for Payer: Humana ChoiceCare |
$1.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.17
|
| Rate for Payer: PHCS All Commercial |
$0.98
|
| Rate for Payer: PHP All Commercial |
$0.99
|
| Rate for Payer: Sagamore Health Network All Products |
$1.01
|
| Rate for Payer: Signature Care EPO |
$1.08
|
| Rate for Payer: Signature Care PPO |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
|
|
FOLIC ACID 5 MG/ML INJ SOLN
|
Facility
OP
|
$319.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.28 |
| Max. Negotiated Rate |
$296.69 |
| Rate for Payer: Aetna Commercial |
$269.25
|
| Rate for Payer: Aetna Medicare |
$105.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$105.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$183.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$199.42
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$121.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$115.80
|
| Rate for Payer: Cash Price |
$197.79
|
| Rate for Payer: Centivo All Commercial |
$162.70
|
| Rate for Payer: Cigna All Commercial |
$275.31
|
| Rate for Payer: CORVEL All Commercial |
$296.69
|
| Rate for Payer: Coventry All Commercial |
$280.74
|
| Rate for Payer: Encore All Commercial |
$293.66
|
| Rate for Payer: Frontpath All Commercial |
$293.50
|
| Rate for Payer: Humana ChoiceCare |
$275.54
|
| Rate for Payer: Humana Medicare |
$162.70
|
| Rate for Payer: Lucent All Commercial |
$162.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$287.12
|
| Rate for Payer: PHCS All Commercial |
$239.26
|
| Rate for Payer: PHP All Commercial |
$241.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$124.42
|
| Rate for Payer: Sagamore Health Network All Products |
$246.28
|
| Rate for Payer: Signature Care EPO |
$264.79
|
| Rate for Payer: Signature Care PPO |
$280.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$271.17
|
| Rate for Payer: United Healthcare Commercial |
$251.39
|
| Rate for Payer: United Healthcare Medicare |
$105.28
|
|
|
FOLIC ACID 5 MG/ML INJ SOLN
|
Facility
IP
|
$319.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$239.26 |
| Max. Negotiated Rate |
$296.69 |
| Rate for Payer: Aetna Commercial |
$275.63
|
| Rate for Payer: Cash Price |
$197.79
|
| Rate for Payer: Cigna All Commercial |
$275.31
|
| Rate for Payer: CORVEL All Commercial |
$296.69
|
| Rate for Payer: Coventry All Commercial |
$280.74
|
| Rate for Payer: Encore All Commercial |
$293.66
|
| Rate for Payer: Frontpath All Commercial |
$293.50
|
| Rate for Payer: Humana ChoiceCare |
$275.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$287.12
|
| Rate for Payer: PHCS All Commercial |
$239.26
|
| Rate for Payer: PHP All Commercial |
$241.94
|
| Rate for Payer: Sagamore Health Network All Products |
$246.28
|
| Rate for Payer: Signature Care EPO |
$264.79
|
| Rate for Payer: Signature Care PPO |
$280.74
|
| Rate for Payer: United Healthcare Commercial |
$251.39
|
|
|
FOMEPIZOLE 1 G/ML IV SOLN
|
Facility
IP
|
$1,953.92
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
22185
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,465.44 |
| Max. Negotiated Rate |
$1,817.14 |
| Rate for Payer: Aetna Commercial |
$1,688.19
|
| Rate for Payer: Cash Price |
$1,211.43
|
| Rate for Payer: Cigna All Commercial |
$1,686.23
|
| Rate for Payer: CORVEL All Commercial |
$1,817.14
|
| Rate for Payer: Coventry All Commercial |
$1,719.45
|
| Rate for Payer: Encore All Commercial |
$1,798.58
|
| Rate for Payer: Frontpath All Commercial |
$1,797.60
|
| Rate for Payer: Humana ChoiceCare |
$1,687.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,758.53
|
| Rate for Payer: PHCS All Commercial |
$1,465.44
|
| Rate for Payer: PHP All Commercial |
$1,481.85
|
| Rate for Payer: Sagamore Health Network All Products |
$1,508.42
|
| Rate for Payer: Signature Care EPO |
$1,621.75
|
| Rate for Payer: Signature Care PPO |
$1,719.45
|
| Rate for Payer: United Healthcare Commercial |
$1,539.69
|
|
|
FOMEPIZOLE 1 G/ML IV SOLN
|
Facility
OP
|
$1,953.92
|
|
|
Service Code
|
HCPCS J1451
|
| Hospital Charge Code |
22185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.35 |
| Max. Negotiated Rate |
$1,817.14 |
| Rate for Payer: Aetna Commercial |
$1,649.11
|
| Rate for Payer: Aetna Medicare |
$644.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$644.79
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,122.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,221.39
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$10.35
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$741.51
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$709.27
|
| Rate for Payer: Cash Price |
$1,211.43
|
| Rate for Payer: Cash Price |
$1,211.43
|
| Rate for Payer: Centivo All Commercial |
$996.50
|
| Rate for Payer: Cigna All Commercial |
$1,686.23
|
| Rate for Payer: CORVEL All Commercial |
$1,817.14
|
| Rate for Payer: Coventry All Commercial |
$1,719.45
|
| Rate for Payer: Encore All Commercial |
$1,798.58
|
| Rate for Payer: Frontpath All Commercial |
$1,797.60
|
| Rate for Payer: Humana ChoiceCare |
$1,687.60
|
| Rate for Payer: Humana Medicare |
$996.50
|
| Rate for Payer: Lucent All Commercial |
$996.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,758.53
|
| Rate for Payer: Managed Health Services Medicaid |
$10.35
|
| Rate for Payer: MDWise Medicaid |
$10.35
|
| Rate for Payer: PHCS All Commercial |
$1,465.44
|
| Rate for Payer: PHP All Commercial |
$1,481.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$762.03
|
| Rate for Payer: Sagamore Health Network All Products |
$1,508.42
|
| Rate for Payer: Signature Care EPO |
$1,621.75
|
| Rate for Payer: Signature Care PPO |
$1,719.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,660.83
|
| Rate for Payer: United Healthcare Commercial |
$1,539.69
|
| Rate for Payer: United Healthcare Medicare |
$644.79
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBQ SYRG
|
Facility
IP
|
$66.52
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
32215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.89 |
| Max. Negotiated Rate |
$61.86 |
| Rate for Payer: Aetna Commercial |
$57.47
|
| Rate for Payer: Cash Price |
$41.24
|
| Rate for Payer: Cigna All Commercial |
$57.41
|
| Rate for Payer: CORVEL All Commercial |
$61.86
|
| Rate for Payer: Coventry All Commercial |
$58.54
|
| Rate for Payer: Encore All Commercial |
$61.23
|
| Rate for Payer: Frontpath All Commercial |
$61.20
|
| Rate for Payer: Humana ChoiceCare |
$57.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.87
|
| Rate for Payer: PHCS All Commercial |
$49.89
|
| Rate for Payer: PHP All Commercial |
$50.45
|
| Rate for Payer: Sagamore Health Network All Products |
$51.35
|
| Rate for Payer: Signature Care EPO |
$55.21
|
| Rate for Payer: Signature Care PPO |
$58.54
|
| Rate for Payer: United Healthcare Commercial |
$52.42
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBQ SYRG
|
Facility
OP
|
$66.52
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
32215
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$61.86 |
| Rate for Payer: Aetna Commercial |
$56.14
|
| Rate for Payer: Aetna Medicare |
$21.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$38.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$41.58
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$25.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.15
|
| Rate for Payer: Cash Price |
$41.24
|
| Rate for Payer: Cash Price |
$41.24
|
| Rate for Payer: Centivo All Commercial |
$33.93
|
| Rate for Payer: Cigna All Commercial |
$57.41
|
| Rate for Payer: CORVEL All Commercial |
$61.86
|
| Rate for Payer: Coventry All Commercial |
$58.54
|
| Rate for Payer: Encore All Commercial |
$61.23
|
| Rate for Payer: Frontpath All Commercial |
$61.20
|
| Rate for Payer: Humana ChoiceCare |
$57.45
|
| Rate for Payer: Humana Medicare |
$33.93
|
| Rate for Payer: Lucent All Commercial |
$33.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.87
|
| Rate for Payer: Managed Health Services Medicaid |
$1.84
|
| Rate for Payer: MDWise Medicaid |
$1.84
|
| Rate for Payer: PHCS All Commercial |
$49.89
|
| Rate for Payer: PHP All Commercial |
$50.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$25.94
|
| Rate for Payer: Sagamore Health Network All Products |
$51.35
|
| Rate for Payer: Signature Care EPO |
$55.21
|
| Rate for Payer: Signature Care PPO |
$58.54
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$56.54
|
| Rate for Payer: United Healthcare Commercial |
$52.42
|
| Rate for Payer: United Healthcare Medicare |
$21.95
|
|
