|
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK
|
Facility
IP
|
$334.80
|
|
|
Service Code
|
NDC 00456430001
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$251.10 |
| Max. Negotiated Rate |
$311.36 |
| Rate for Payer: Aetna Commercial |
$289.27
|
| Rate for Payer: Cash Price |
$207.58
|
| Rate for Payer: Cigna All Commercial |
$288.93
|
| Rate for Payer: CORVEL All Commercial |
$311.36
|
| Rate for Payer: Coventry All Commercial |
$294.62
|
| Rate for Payer: Encore All Commercial |
$308.18
|
| Rate for Payer: Frontpath All Commercial |
$308.02
|
| Rate for Payer: Humana ChoiceCare |
$289.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$301.32
|
| Rate for Payer: PHCS All Commercial |
$251.10
|
| Rate for Payer: PHP All Commercial |
$253.91
|
| Rate for Payer: Sagamore Health Network All Products |
$258.47
|
| Rate for Payer: Signature Care EPO |
$277.88
|
| Rate for Payer: Signature Care PPO |
$294.62
|
| Rate for Payer: United Healthcare Commercial |
$263.82
|
|
|
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK
|
Facility
OP
|
$334.80
|
|
|
Service Code
|
NDC 00456430001
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.48 |
| Max. Negotiated Rate |
$311.36 |
| Rate for Payer: Aetna Commercial |
$282.57
|
| Rate for Payer: Aetna Medicare |
$110.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$110.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$192.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$209.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$127.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$121.53
|
| Rate for Payer: Cash Price |
$207.58
|
| Rate for Payer: Centivo All Commercial |
$170.75
|
| Rate for Payer: Cigna All Commercial |
$288.93
|
| Rate for Payer: CORVEL All Commercial |
$311.36
|
| Rate for Payer: Coventry All Commercial |
$294.62
|
| Rate for Payer: Encore All Commercial |
$308.18
|
| Rate for Payer: Frontpath All Commercial |
$308.02
|
| Rate for Payer: Humana ChoiceCare |
$289.17
|
| Rate for Payer: Humana Medicare |
$170.75
|
| Rate for Payer: Lucent All Commercial |
$170.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$301.32
|
| Rate for Payer: PHCS All Commercial |
$251.10
|
| Rate for Payer: PHP All Commercial |
$253.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$130.57
|
| Rate for Payer: Sagamore Health Network All Products |
$258.47
|
| Rate for Payer: Signature Care EPO |
$277.88
|
| Rate for Payer: Signature Care PPO |
$294.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$284.58
|
| Rate for Payer: United Healthcare Commercial |
$263.82
|
| Rate for Payer: United Healthcare Medicare |
$110.48
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN
|
Facility
IP
|
$268.45
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$201.34 |
| Max. Negotiated Rate |
$249.66 |
| Rate for Payer: Aetna Commercial |
$231.94
|
| Rate for Payer: Cash Price |
$166.44
|
| Rate for Payer: Cigna All Commercial |
$231.67
|
| Rate for Payer: CORVEL All Commercial |
$249.66
|
| Rate for Payer: Coventry All Commercial |
$236.24
|
| Rate for Payer: Encore All Commercial |
$247.11
|
| Rate for Payer: Frontpath All Commercial |
$246.97
|
| Rate for Payer: Humana ChoiceCare |
$231.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$241.60
|
| Rate for Payer: PHCS All Commercial |
$201.34
|
| Rate for Payer: PHP All Commercial |
$203.59
|
| Rate for Payer: Sagamore Health Network All Products |
$207.24
|
| Rate for Payer: Signature Care EPO |
$222.81
|
| Rate for Payer: Signature Care PPO |
$236.24
|
| Rate for Payer: United Healthcare Commercial |
$211.54
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN
|
Facility
OP
|
$268.45
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.59 |
| Max. Negotiated Rate |
$249.66 |
| Rate for Payer: Aetna Commercial |
$226.57
|
| Rate for Payer: Aetna Medicare |
$88.59
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$88.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$154.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$167.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$101.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$97.45
|
| Rate for Payer: Cash Price |
$166.44
|
| Rate for Payer: Centivo All Commercial |
$136.91
|
| Rate for Payer: Cigna All Commercial |
$231.67
|
| Rate for Payer: CORVEL All Commercial |
$249.66
|
| Rate for Payer: Coventry All Commercial |
$236.24
|
| Rate for Payer: Encore All Commercial |
$247.11
|
| Rate for Payer: Frontpath All Commercial |
$246.97
|
| Rate for Payer: Humana ChoiceCare |
$231.86
|
| Rate for Payer: Humana Medicare |
$136.91
|
| Rate for Payer: Lucent All Commercial |
$136.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$241.60
|
| Rate for Payer: PHCS All Commercial |
$201.34
|
| Rate for Payer: PHP All Commercial |
$203.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$104.70
|
| Rate for Payer: Sagamore Health Network All Products |
$207.24
|
| Rate for Payer: Signature Care EPO |
$222.81
|
| Rate for Payer: Signature Care PPO |
$236.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$228.18
|
| Rate for Payer: United Healthcare Commercial |
$211.54
|
| Rate for Payer: United Healthcare Medicare |
$88.59
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN
|
Facility
IP
|
$575.25
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$431.44 |
| Max. Negotiated Rate |
$534.98 |
| Rate for Payer: Aetna Commercial |
$497.02
|
| Rate for Payer: Cash Price |
$356.66
|
| Rate for Payer: Cigna All Commercial |
$496.44
|
| Rate for Payer: CORVEL All Commercial |
$534.98
|
| Rate for Payer: Coventry All Commercial |
$506.22
|
| Rate for Payer: Encore All Commercial |
$529.52
|
| Rate for Payer: Frontpath All Commercial |
$529.23
|
| Rate for Payer: Humana ChoiceCare |
$496.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$517.72
|
| Rate for Payer: PHCS All Commercial |
$431.44
|
| Rate for Payer: PHP All Commercial |
$436.27
|
| Rate for Payer: Sagamore Health Network All Products |
$444.09
|
| Rate for Payer: Signature Care EPO |
$477.46
|
| Rate for Payer: Signature Care PPO |
$506.22
|
| Rate for Payer: United Healthcare Commercial |
$453.30
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN
|
Facility
OP
|
$575.25
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.83 |
| Max. Negotiated Rate |
$534.98 |
| Rate for Payer: Aetna Commercial |
$485.51
|
| Rate for Payer: Aetna Medicare |
$189.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$189.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$330.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$359.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$218.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$208.82
|
| Rate for Payer: Cash Price |
$356.66
|
| Rate for Payer: Centivo All Commercial |
$293.38
|
| Rate for Payer: Cigna All Commercial |
$496.44
|
| Rate for Payer: CORVEL All Commercial |
$534.98
|
| Rate for Payer: Coventry All Commercial |
$506.22
|
| Rate for Payer: Encore All Commercial |
$529.52
|
| Rate for Payer: Frontpath All Commercial |
$529.23
|
| Rate for Payer: Humana ChoiceCare |
$496.84
|
| Rate for Payer: Humana Medicare |
$293.38
|
| Rate for Payer: Lucent All Commercial |
$293.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$517.72
|
| Rate for Payer: PHCS All Commercial |
$431.44
|
| Rate for Payer: PHP All Commercial |
$436.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$224.35
|
| Rate for Payer: Sagamore Health Network All Products |
$444.09
|
| Rate for Payer: Signature Care EPO |
$477.46
|
| Rate for Payer: Signature Care PPO |
$506.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$488.96
|
| Rate for Payer: United Healthcare Commercial |
$453.30
|
| Rate for Payer: United Healthcare Medicare |
$189.83
|
|
|
FULVESTRANT 250 MG/5 ML IM SYRG
|
Facility
IP
|
$6,617.00
|
|
|
Service Code
|
HCPCS J9395
|
| Hospital Charge Code |
32767
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,962.75 |
| Max. Negotiated Rate |
$6,153.81 |
| Rate for Payer: Aetna Commercial |
$5,717.08
|
| Rate for Payer: Cash Price |
$4,102.54
|
| Rate for Payer: Cigna All Commercial |
$5,710.47
|
| Rate for Payer: CORVEL All Commercial |
$6,153.81
|
| Rate for Payer: Coventry All Commercial |
$5,822.96
|
| Rate for Payer: Encore All Commercial |
$6,090.94
|
| Rate for Payer: Frontpath All Commercial |
$6,087.64
|
| Rate for Payer: Humana ChoiceCare |
$5,715.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,955.30
|
| Rate for Payer: PHCS All Commercial |
$4,962.75
|
| Rate for Payer: PHP All Commercial |
$5,018.33
|
| Rate for Payer: Sagamore Health Network All Products |
$5,108.32
|
| Rate for Payer: Signature Care EPO |
$5,492.11
|
| Rate for Payer: Signature Care PPO |
$5,822.96
|
| Rate for Payer: United Healthcare Commercial |
$5,214.19
|
|
|
FULVESTRANT 250 MG/5 ML IM SYRG
|
Facility
OP
|
$6,617.00
|
|
|
Service Code
|
HCPCS J9395
|
| Hospital Charge Code |
32767
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$6,153.81 |
| Rate for Payer: Aetna Commercial |
$5,584.74
|
| Rate for Payer: Aetna Medicare |
$2,183.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,183.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,800.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,136.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$10.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,511.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,401.97
|
| Rate for Payer: Cash Price |
$4,102.54
|
| Rate for Payer: Cash Price |
$4,102.54
|
| Rate for Payer: Centivo All Commercial |
$3,374.67
|
| Rate for Payer: Cigna All Commercial |
$5,710.47
|
| Rate for Payer: CORVEL All Commercial |
$6,153.81
|
| Rate for Payer: Coventry All Commercial |
$5,822.96
|
| Rate for Payer: Encore All Commercial |
$6,090.94
|
| Rate for Payer: Frontpath All Commercial |
$6,087.64
|
| Rate for Payer: Humana ChoiceCare |
$5,715.10
|
| Rate for Payer: Humana Medicare |
$3,374.67
|
| Rate for Payer: Lucent All Commercial |
$3,374.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,955.30
|
| Rate for Payer: Managed Health Services Medicaid |
$10.50
|
| Rate for Payer: MDWise Medicaid |
$10.50
|
| Rate for Payer: PHCS All Commercial |
$4,962.75
|
| Rate for Payer: PHP All Commercial |
$5,018.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,580.63
|
| Rate for Payer: Sagamore Health Network All Products |
$5,108.32
|
| Rate for Payer: Signature Care EPO |
$5,492.11
|
| Rate for Payer: Signature Care PPO |
$5,822.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,624.45
|
| Rate for Payer: United Healthcare Commercial |
$5,214.19
|
| Rate for Payer: United Healthcare Medicare |
$2,183.61
|
|
|
FUROSEMIDE 10 MG/ML INJ SOLN
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
3291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$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
|
|
|
FUROSEMIDE 10 MG/ML INJ SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
3291
|
|
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
|
|
|
FUROSEMIDE 20 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 51079007220
|
| Hospital Charge Code |
3294
|
|
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
|
|
|
FUROSEMIDE 20 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 51079007220
|
| Hospital Charge Code |
3294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| 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
|
|
|
FUROSEMIDE 40 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 51079007320
|
| Hospital Charge Code |
3295
|
|
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
|
|
|
FUROSEMIDE 40 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 51079007320
|
| Hospital Charge Code |
3295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| 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
|
|
|
GABAPENTIN 100 MG ORAL CAP
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904666561
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| 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
|
|
|
GABAPENTIN 100 MG ORAL CAP
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904666561
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| 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
|
|
|
GABAPENTIN 300 MG ORAL CAP
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687059101
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| 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
|
|
|
GABAPENTIN 300 MG ORAL CAP
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687059111
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| 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
|
|
|
GABAPENTIN 300 MG ORAL CAP
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687059111
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| 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
|
|
|
GABAPENTIN 300 MG ORAL CAP
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687059101
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| 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
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN 10 ML VIAL
|
Facility
IP
|
$331.02
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$248.26 |
| Max. Negotiated Rate |
$307.85 |
| Rate for Payer: Aetna Commercial |
$286.00
|
| Rate for Payer: Cash Price |
$205.23
|
| Rate for Payer: Cigna All Commercial |
$285.67
|
| Rate for Payer: CORVEL All Commercial |
$307.85
|
| Rate for Payer: Coventry All Commercial |
$291.30
|
| Rate for Payer: Encore All Commercial |
$304.70
|
| Rate for Payer: Frontpath All Commercial |
$304.54
|
| Rate for Payer: Humana ChoiceCare |
$285.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.92
|
| Rate for Payer: PHCS All Commercial |
$248.26
|
| Rate for Payer: PHP All Commercial |
$251.05
|
| Rate for Payer: Sagamore Health Network All Products |
$255.55
|
| Rate for Payer: Signature Care EPO |
$274.75
|
| Rate for Payer: Signature Care PPO |
$291.30
|
| Rate for Payer: United Healthcare Commercial |
$260.84
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN 10 ML VIAL
|
Facility
OP
|
$331.02
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.24 |
| Max. Negotiated Rate |
$307.85 |
| Rate for Payer: Aetna Commercial |
$279.38
|
| Rate for Payer: Aetna Medicare |
$109.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$109.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$190.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$206.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$125.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$120.16
|
| Rate for Payer: Cash Price |
$205.23
|
| Rate for Payer: Centivo All Commercial |
$168.82
|
| Rate for Payer: Cigna All Commercial |
$285.67
|
| Rate for Payer: CORVEL All Commercial |
$307.85
|
| Rate for Payer: Coventry All Commercial |
$291.30
|
| Rate for Payer: Encore All Commercial |
$304.70
|
| Rate for Payer: Frontpath All Commercial |
$304.54
|
| Rate for Payer: Humana ChoiceCare |
$285.90
|
| Rate for Payer: Humana Medicare |
$168.82
|
| Rate for Payer: Lucent All Commercial |
$168.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.92
|
| Rate for Payer: PHCS All Commercial |
$248.26
|
| Rate for Payer: PHP All Commercial |
$251.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$129.10
|
| Rate for Payer: Sagamore Health Network All Products |
$255.55
|
| Rate for Payer: Signature Care EPO |
$274.75
|
| Rate for Payer: Signature Care PPO |
$291.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$281.37
|
| Rate for Payer: United Healthcare Commercial |
$260.84
|
| Rate for Payer: United Healthcare Medicare |
$109.24
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN 20 ML VIAL
|
Facility
OP
|
$598.20
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
408411371
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$197.41 |
| Max. Negotiated Rate |
$556.33 |
| Rate for Payer: Aetna Commercial |
$504.88
|
| Rate for Payer: Aetna Medicare |
$197.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$197.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$343.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$373.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$227.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$217.15
|
| Rate for Payer: Cash Price |
$370.88
|
| Rate for Payer: Centivo All Commercial |
$305.08
|
| Rate for Payer: Cigna All Commercial |
$516.25
|
| Rate for Payer: CORVEL All Commercial |
$556.33
|
| Rate for Payer: Coventry All Commercial |
$526.42
|
| Rate for Payer: Encore All Commercial |
$550.64
|
| Rate for Payer: Frontpath All Commercial |
$550.34
|
| Rate for Payer: Humana ChoiceCare |
$516.67
|
| Rate for Payer: Humana Medicare |
$305.08
|
| Rate for Payer: Lucent All Commercial |
$305.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$538.38
|
| Rate for Payer: PHCS All Commercial |
$448.65
|
| Rate for Payer: PHP All Commercial |
$453.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$233.30
|
| Rate for Payer: Sagamore Health Network All Products |
$461.81
|
| Rate for Payer: Signature Care EPO |
$496.51
|
| Rate for Payer: Signature Care PPO |
$526.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$508.47
|
| Rate for Payer: United Healthcare Commercial |
$471.38
|
| Rate for Payer: United Healthcare Medicare |
$197.41
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN 20 ML VIAL
|
Facility
IP
|
$598.20
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
408411371
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$448.65 |
| Max. Negotiated Rate |
$556.33 |
| Rate for Payer: Aetna Commercial |
$516.84
|
| Rate for Payer: Cash Price |
$370.88
|
| Rate for Payer: Cigna All Commercial |
$516.25
|
| Rate for Payer: CORVEL All Commercial |
$556.33
|
| Rate for Payer: Coventry All Commercial |
$526.42
|
| Rate for Payer: Encore All Commercial |
$550.64
|
| Rate for Payer: Frontpath All Commercial |
$550.34
|
| Rate for Payer: Humana ChoiceCare |
$516.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$538.38
|
| Rate for Payer: PHCS All Commercial |
$448.65
|
| Rate for Payer: PHP All Commercial |
$453.67
|
| Rate for Payer: Sagamore Health Network All Products |
$461.81
|
| Rate for Payer: Signature Care EPO |
$496.51
|
| Rate for Payer: Signature Care PPO |
$526.42
|
| Rate for Payer: United Healthcare Commercial |
$471.38
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN
|
Facility
IP
|
$185.50
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
165683
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$139.12 |
| Max. Negotiated Rate |
$172.52 |
| Rate for Payer: Aetna Commercial |
$160.27
|
| Rate for Payer: Cash Price |
$115.01
|
| Rate for Payer: Cigna All Commercial |
$160.09
|
| Rate for Payer: CORVEL All Commercial |
$172.52
|
| Rate for Payer: Coventry All Commercial |
$163.24
|
| Rate for Payer: Encore All Commercial |
$170.75
|
| Rate for Payer: Frontpath All Commercial |
$170.66
|
| Rate for Payer: Humana ChoiceCare |
$160.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$166.95
|
| Rate for Payer: PHCS All Commercial |
$139.12
|
| Rate for Payer: PHP All Commercial |
$140.68
|
| Rate for Payer: Sagamore Health Network All Products |
$143.21
|
| Rate for Payer: Signature Care EPO |
$153.96
|
| Rate for Payer: Signature Care PPO |
$163.24
|
| Rate for Payer: United Healthcare Commercial |
$146.17
|
|
