|
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
105614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
105614
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN
|
Facility
|
OP
|
$102.21
|
|
|
Service Code
|
HCPCS J2360
|
| Hospital Charge Code |
5886
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.69 |
| Max. Negotiated Rate |
$95.06 |
| Rate for Payer: Aetna Commercial |
$86.27
|
| Rate for Payer: Aetna Commercial |
$85.71
|
| Rate for Payer: Aetna Medicare |
$32.71
|
| Rate for Payer: Aetna Medicare |
$32.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$58.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$58.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$63.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$63.89
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$37.61
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$37.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35.98
|
| Rate for Payer: Cash Price |
$61.33
|
| Rate for Payer: Cash Price |
$60.93
|
| Rate for Payer: Centivo All Commercial |
$55.25
|
| Rate for Payer: Centivo All Commercial |
$55.60
|
| Rate for Payer: Cigna All Commercial |
$88.21
|
| Rate for Payer: Cigna All Commercial |
$87.64
|
| Rate for Payer: CORVEL All Commercial |
$94.45
|
| Rate for Payer: CORVEL All Commercial |
$95.06
|
| Rate for Payer: Coventry All Commercial |
$89.37
|
| Rate for Payer: Coventry All Commercial |
$89.95
|
| Rate for Payer: Encore All Commercial |
$94.09
|
| Rate for Payer: Encore All Commercial |
$93.48
|
| Rate for Payer: Frontpath All Commercial |
$93.43
|
| Rate for Payer: Frontpath All Commercial |
$94.04
|
| Rate for Payer: Humana ChoiceCare |
$88.28
|
| Rate for Payer: Humana ChoiceCare |
$87.71
|
| Rate for Payer: Humana Medicare |
$32.71
|
| Rate for Payer: Humana Medicare |
$32.50
|
| Rate for Payer: Lucent All Commercial |
$55.25
|
| Rate for Payer: Lucent All Commercial |
$55.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.40
|
| Rate for Payer: PHCS All Commercial |
$76.17
|
| Rate for Payer: PHCS All Commercial |
$76.66
|
| Rate for Payer: PHP All Commercial |
$77.02
|
| Rate for Payer: PHP All Commercial |
$77.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.61
|
| Rate for Payer: Sagamore Health Network All Products |
$78.40
|
| Rate for Payer: Sagamore Health Network All Products |
$78.91
|
| Rate for Payer: Signature Care EPO |
$84.84
|
| Rate for Payer: Signature Care EPO |
$84.29
|
| Rate for Payer: Signature Care PPO |
$89.37
|
| Rate for Payer: Signature Care PPO |
$89.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$86.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$86.32
|
| Rate for Payer: United Healthcare Commercial |
$80.03
|
| Rate for Payer: United Healthcare Commercial |
$80.54
|
| Rate for Payer: United Healthcare Medicare |
$32.50
|
| Rate for Payer: United Healthcare Medicare |
$32.71
|
|
|
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN
|
Facility
|
IP
|
$101.56
|
|
|
Service Code
|
HCPCS J2360
|
| Hospital Charge Code |
5886
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.17 |
| Max. Negotiated Rate |
$94.45 |
| Rate for Payer: Aetna Commercial |
$87.74
|
| Rate for Payer: Aetna Commercial |
$88.31
|
| Rate for Payer: Cash Price |
$60.93
|
| Rate for Payer: Cash Price |
$61.33
|
| Rate for Payer: Cigna All Commercial |
$87.64
|
| Rate for Payer: Cigna All Commercial |
$88.21
|
| Rate for Payer: CORVEL All Commercial |
$94.45
|
| Rate for Payer: CORVEL All Commercial |
$95.06
|
| Rate for Payer: Coventry All Commercial |
$89.95
|
| Rate for Payer: Coventry All Commercial |
$89.37
|
| Rate for Payer: Encore All Commercial |
$94.09
|
| Rate for Payer: Encore All Commercial |
$93.48
|
| Rate for Payer: Frontpath All Commercial |
$93.43
|
| Rate for Payer: Frontpath All Commercial |
$94.04
|
| Rate for Payer: Humana ChoiceCare |
$87.71
|
| Rate for Payer: Humana ChoiceCare |
$88.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$91.99
|
| Rate for Payer: PHCS All Commercial |
$76.66
|
| Rate for Payer: PHCS All Commercial |
$76.17
|
| Rate for Payer: PHP All Commercial |
$77.02
|
| Rate for Payer: PHP All Commercial |
$77.52
|
| Rate for Payer: Sagamore Health Network All Products |
$78.91
|
| Rate for Payer: Sagamore Health Network All Products |
$78.40
|
| Rate for Payer: Signature Care EPO |
$84.84
|
| Rate for Payer: Signature Care EPO |
$84.29
|
| Rate for Payer: Signature Care PPO |
$89.37
|
| Rate for Payer: Signature Care PPO |
$89.95
|
| Rate for Payer: United Healthcare Commercial |
$80.03
|
| Rate for Payer: United Healthcare Commercial |
$80.54
|
|
|
OSELTAMIVIR 30 MG ORAL CAP
|
Facility
|
IP
|
$7.97
|
|
|
Service Code
|
NDC 68180067511
|
| Hospital Charge Code |
88704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.98 |
| Max. Negotiated Rate |
$7.41 |
| Rate for Payer: Aetna Commercial |
$6.89
|
| Rate for Payer: Cash Price |
$4.78
|
| Rate for Payer: Cigna All Commercial |
$6.88
|
| Rate for Payer: CORVEL All Commercial |
$7.41
|
| Rate for Payer: Coventry All Commercial |
$7.02
|
| Rate for Payer: Encore All Commercial |
$7.34
|
| Rate for Payer: Frontpath All Commercial |
$7.34
|
| Rate for Payer: Humana ChoiceCare |
$6.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.18
|
| Rate for Payer: PHCS All Commercial |
$5.98
|
| Rate for Payer: PHP All Commercial |
$6.05
|
| Rate for Payer: Sagamore Health Network All Products |
$6.16
|
| Rate for Payer: Signature Care EPO |
$6.62
|
| Rate for Payer: Signature Care PPO |
$7.02
|
| Rate for Payer: United Healthcare Commercial |
$6.28
|
|
|
OSELTAMIVIR 30 MG ORAL CAP
|
Facility
|
OP
|
$7.97
|
|
|
Service Code
|
NDC 68180067511
|
| Hospital Charge Code |
88704
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.47 |
| Max. Negotiated Rate |
$7.41 |
| Rate for Payer: Aetna Commercial |
$6.73
|
| Rate for Payer: Aetna Medicare |
$2.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.81
|
| Rate for Payer: Cash Price |
$4.78
|
| Rate for Payer: Centivo All Commercial |
$4.34
|
| Rate for Payer: Cigna All Commercial |
$6.88
|
| Rate for Payer: CORVEL All Commercial |
$7.41
|
| Rate for Payer: Coventry All Commercial |
$7.02
|
| Rate for Payer: Encore All Commercial |
$7.34
|
| Rate for Payer: Frontpath All Commercial |
$7.34
|
| Rate for Payer: Humana ChoiceCare |
$6.89
|
| Rate for Payer: Humana Medicare |
$2.55
|
| Rate for Payer: Lucent All Commercial |
$4.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.18
|
| Rate for Payer: PHCS All Commercial |
$5.98
|
| Rate for Payer: PHP All Commercial |
$6.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.11
|
| Rate for Payer: Sagamore Health Network All Products |
$6.16
|
| Rate for Payer: Signature Care EPO |
$6.62
|
| Rate for Payer: Signature Care PPO |
$7.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.78
|
| Rate for Payer: United Healthcare Commercial |
$6.28
|
| Rate for Payer: United Healthcare Medicare |
$2.55
|
|
|
OSELTAMIVIR 6 MG/ML ORAL SUSR
|
Facility
|
IP
|
$114.24
|
|
|
Service Code
|
NDC 68180067801
|
| Hospital Charge Code |
152586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.68 |
| Max. Negotiated Rate |
$106.24 |
| Rate for Payer: Aetna Commercial |
$98.70
|
| Rate for Payer: Cash Price |
$68.54
|
| Rate for Payer: Cigna All Commercial |
$98.59
|
| Rate for Payer: CORVEL All Commercial |
$106.24
|
| Rate for Payer: Coventry All Commercial |
$100.53
|
| Rate for Payer: Encore All Commercial |
$105.16
|
| Rate for Payer: Frontpath All Commercial |
$105.10
|
| Rate for Payer: Humana ChoiceCare |
$98.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$102.82
|
| Rate for Payer: PHCS All Commercial |
$85.68
|
| Rate for Payer: PHP All Commercial |
$86.64
|
| Rate for Payer: Sagamore Health Network All Products |
$88.19
|
| Rate for Payer: Signature Care EPO |
$94.82
|
| Rate for Payer: Signature Care PPO |
$100.53
|
| Rate for Payer: United Healthcare Commercial |
$90.02
|
|
|
OSELTAMIVIR 6 MG/ML ORAL SUSR
|
Facility
|
OP
|
$114.24
|
|
|
Service Code
|
NDC 68180067801
|
| Hospital Charge Code |
152586
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.41 |
| Max. Negotiated Rate |
$106.24 |
| Rate for Payer: Aetna Commercial |
$96.42
|
| Rate for Payer: Aetna Medicare |
$36.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$65.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$71.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$42.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$40.21
|
| Rate for Payer: Cash Price |
$68.54
|
| Rate for Payer: Centivo All Commercial |
$62.15
|
| Rate for Payer: Cigna All Commercial |
$98.59
|
| Rate for Payer: CORVEL All Commercial |
$106.24
|
| Rate for Payer: Coventry All Commercial |
$100.53
|
| Rate for Payer: Encore All Commercial |
$105.16
|
| Rate for Payer: Frontpath All Commercial |
$105.10
|
| Rate for Payer: Humana ChoiceCare |
$98.67
|
| Rate for Payer: Humana Medicare |
$36.56
|
| Rate for Payer: Lucent All Commercial |
$62.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$102.82
|
| Rate for Payer: PHCS All Commercial |
$85.68
|
| Rate for Payer: PHP All Commercial |
$86.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$44.55
|
| Rate for Payer: Sagamore Health Network All Products |
$88.19
|
| Rate for Payer: Signature Care EPO |
$94.82
|
| Rate for Payer: Signature Care PPO |
$100.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$97.10
|
| Rate for Payer: United Healthcare Commercial |
$90.02
|
| Rate for Payer: United Healthcare Medicare |
$36.56
|
|
|
OSELTAMIVIR 6 MG/ML ORAL SUSR 60 ML ED PACK
|
Facility
|
OP
|
$559.44
|
|
|
Service Code
|
NDC 47781384
|
| Hospital Charge Code |
800685
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.43 |
| Max. Negotiated Rate |
$520.28 |
| Rate for Payer: Aetna Commercial |
$472.17
|
| Rate for Payer: Aetna Medicare |
$179.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$173.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$321.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$349.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$205.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$196.92
|
| Rate for Payer: Cash Price |
$335.66
|
| Rate for Payer: Centivo All Commercial |
$304.34
|
| Rate for Payer: Cigna All Commercial |
$482.80
|
| Rate for Payer: CORVEL All Commercial |
$520.28
|
| Rate for Payer: Coventry All Commercial |
$492.31
|
| Rate for Payer: Encore All Commercial |
$514.96
|
| Rate for Payer: Frontpath All Commercial |
$514.68
|
| Rate for Payer: Humana ChoiceCare |
$483.19
|
| Rate for Payer: Humana Medicare |
$179.02
|
| Rate for Payer: Lucent All Commercial |
$304.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$503.50
|
| Rate for Payer: PHCS All Commercial |
$419.58
|
| Rate for Payer: PHP All Commercial |
$424.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$218.18
|
| Rate for Payer: Sagamore Health Network All Products |
$431.89
|
| Rate for Payer: Signature Care EPO |
$464.34
|
| Rate for Payer: Signature Care PPO |
$492.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$475.52
|
| Rate for Payer: United Healthcare Commercial |
$440.84
|
| Rate for Payer: United Healthcare Medicare |
$179.02
|
|
|
OSELTAMIVIR 6 MG/ML ORAL SUSR 60 ML ED PACK
|
Facility
|
IP
|
$559.44
|
|
|
Service Code
|
NDC 47781384
|
| Hospital Charge Code |
800685
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$419.58 |
| Max. Negotiated Rate |
$520.28 |
| Rate for Payer: Aetna Commercial |
$483.36
|
| Rate for Payer: Cash Price |
$335.66
|
| Rate for Payer: Cigna All Commercial |
$482.80
|
| Rate for Payer: CORVEL All Commercial |
$520.28
|
| Rate for Payer: Coventry All Commercial |
$492.31
|
| Rate for Payer: Encore All Commercial |
$514.96
|
| Rate for Payer: Frontpath All Commercial |
$514.68
|
| Rate for Payer: Humana ChoiceCare |
$483.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$503.50
|
| Rate for Payer: PHCS All Commercial |
$419.58
|
| Rate for Payer: PHP All Commercial |
$424.28
|
| Rate for Payer: Sagamore Health Network All Products |
$431.89
|
| Rate for Payer: Signature Care EPO |
$464.34
|
| Rate for Payer: Signature Care PPO |
$492.31
|
| Rate for Payer: United Healthcare Commercial |
$440.84
|
|
|
OSELTAMIVIR 75 MG ORAL CAP
|
Facility
|
OP
|
$7.31
|
|
|
Service Code
|
NDC 68180067711
|
| Hospital Charge Code |
26546
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Aetna Commercial |
$6.17
|
| Rate for Payer: Aetna Medicare |
$2.34
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.57
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Centivo All Commercial |
$3.98
|
| Rate for Payer: Cigna All Commercial |
$6.31
|
| Rate for Payer: CORVEL All Commercial |
$6.80
|
| Rate for Payer: Coventry All Commercial |
$6.43
|
| Rate for Payer: Encore All Commercial |
$6.73
|
| Rate for Payer: Frontpath All Commercial |
$6.72
|
| Rate for Payer: Humana ChoiceCare |
$6.31
|
| Rate for Payer: Humana Medicare |
$2.34
|
| Rate for Payer: Lucent All Commercial |
$3.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.58
|
| Rate for Payer: PHCS All Commercial |
$5.48
|
| Rate for Payer: PHP All Commercial |
$5.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.85
|
| Rate for Payer: Sagamore Health Network All Products |
$5.64
|
| Rate for Payer: Signature Care EPO |
$6.07
|
| Rate for Payer: Signature Care PPO |
$6.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.21
|
| Rate for Payer: United Healthcare Commercial |
$5.76
|
| Rate for Payer: United Healthcare Medicare |
$2.34
|
|
|
OSELTAMIVIR 75 MG ORAL CAP
|
Facility
|
IP
|
$7.31
|
|
|
Service Code
|
NDC 68180067711
|
| Hospital Charge Code |
26546
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.48 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Aetna Commercial |
$6.31
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Cigna All Commercial |
$6.31
|
| Rate for Payer: CORVEL All Commercial |
$6.80
|
| Rate for Payer: Coventry All Commercial |
$6.43
|
| Rate for Payer: Encore All Commercial |
$6.73
|
| Rate for Payer: Frontpath All Commercial |
$6.72
|
| Rate for Payer: Humana ChoiceCare |
$6.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.58
|
| Rate for Payer: PHCS All Commercial |
$5.48
|
| Rate for Payer: PHP All Commercial |
$5.54
|
| Rate for Payer: Sagamore Health Network All Products |
$5.64
|
| Rate for Payer: Signature Care EPO |
$6.07
|
| Rate for Payer: Signature Care PPO |
$6.43
|
| Rate for Payer: United Healthcare Commercial |
$5.76
|
|
|
OTHER MENTAL HEALTH DISORDERS
|
Facility
|
IP
|
$2,853.03
|
|
|
Service Code
|
APR-DRG 7602
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$2,853.03 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
OTHER MENTAL HEALTH DISORDERS
|
Facility
|
IP
|
$9,077.84
|
|
|
Service Code
|
APR-DRG 7604
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$9,077.84 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
OTHER MENTAL HEALTH DISORDERS
|
Facility
|
IP
|
$4,452.46
|
|
|
Service Code
|
APR-DRG 7603
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$4,452.46 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
OTHER MENTAL HEALTH DISORDERS
|
Facility
|
IP
|
$2,377.53
|
|
|
Service Code
|
APR-DRG 7601
|
| Min. Negotiated Rate |
$408.50 |
| Max. Negotiated Rate |
$2,377.53 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$408.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$408.50
|
| Rate for Payer: Managed Health Services Medicaid |
$408.50
|
| Rate for Payer: MDWise Medicaid |
$408.50
|
|
|
OXCARBAZEPINE 150 MG ORAL TAB
|
Facility
|
OP
|
$2.53
|
|
|
Service Code
|
NDC 00904726261
|
| Hospital Charge Code |
27049
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna Commercial |
$2.13
|
| Rate for Payer: Aetna Medicare |
$0.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.89
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Centivo All Commercial |
$1.37
|
| Rate for Payer: Cigna All Commercial |
$2.18
|
| Rate for Payer: CORVEL All Commercial |
$2.35
|
| Rate for Payer: Coventry All Commercial |
$2.22
|
| Rate for Payer: Encore All Commercial |
$2.33
|
| Rate for Payer: Frontpath All Commercial |
$2.32
|
| Rate for Payer: Humana ChoiceCare |
$2.18
|
| Rate for Payer: Humana Medicare |
$0.81
|
| Rate for Payer: Lucent All Commercial |
$1.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.27
|
| Rate for Payer: PHCS All Commercial |
$1.90
|
| Rate for Payer: PHP All Commercial |
$1.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.99
|
| Rate for Payer: Sagamore Health Network All Products |
$1.95
|
| Rate for Payer: Signature Care EPO |
$2.10
|
| Rate for Payer: Signature Care PPO |
$2.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.15
|
| Rate for Payer: United Healthcare Commercial |
$1.99
|
| Rate for Payer: United Healthcare Medicare |
$0.81
|
|
|
OXCARBAZEPINE 150 MG ORAL TAB
|
Facility
|
IP
|
$2.53
|
|
|
Service Code
|
NDC 00904726261
|
| Hospital Charge Code |
27049
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.90 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: Cigna All Commercial |
$2.18
|
| Rate for Payer: CORVEL All Commercial |
$2.35
|
| Rate for Payer: Coventry All Commercial |
$2.22
|
| Rate for Payer: Encore All Commercial |
$2.33
|
| Rate for Payer: Frontpath All Commercial |
$2.32
|
| Rate for Payer: Humana ChoiceCare |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.27
|
| Rate for Payer: PHCS All Commercial |
$1.90
|
| Rate for Payer: PHP All Commercial |
$1.92
|
| Rate for Payer: Sagamore Health Network All Products |
$1.95
|
| Rate for Payer: Signature Care EPO |
$2.10
|
| Rate for Payer: Signature Care PPO |
$2.22
|
| Rate for Payer: United Healthcare Commercial |
$1.99
|
|
|
OXYBUTYNIN CHLORIDE 5 MG ORAL TAB
|
Facility
|
IP
|
$1.74
|
|
|
Service Code
|
NDC 00904702761
|
| Hospital Charge Code |
5938
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna Commercial |
$1.50
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cigna All Commercial |
$1.50
|
| Rate for Payer: CORVEL All Commercial |
$1.61
|
| Rate for Payer: Coventry All Commercial |
$1.53
|
| Rate for Payer: Encore All Commercial |
$1.60
|
| Rate for Payer: Frontpath All Commercial |
$1.60
|
| Rate for Payer: Humana ChoiceCare |
$1.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.56
|
| Rate for Payer: PHCS All Commercial |
$1.30
|
| Rate for Payer: PHP All Commercial |
$1.32
|
| Rate for Payer: Sagamore Health Network All Products |
$1.34
|
| Rate for Payer: Signature Care EPO |
$1.44
|
| Rate for Payer: Signature Care PPO |
$1.53
|
| Rate for Payer: United Healthcare Commercial |
$1.37
|
|
|
OXYBUTYNIN CHLORIDE 5 MG ORAL TAB
|
Facility
|
OP
|
$1.74
|
|
|
Service Code
|
NDC 00904702761
|
| Hospital Charge Code |
5938
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna Commercial |
$1.47
|
| Rate for Payer: Aetna Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Centivo All Commercial |
$0.94
|
| Rate for Payer: Cigna All Commercial |
$1.50
|
| Rate for Payer: CORVEL All Commercial |
$1.61
|
| Rate for Payer: Coventry All Commercial |
$1.53
|
| Rate for Payer: Encore All Commercial |
$1.60
|
| Rate for Payer: Frontpath All Commercial |
$1.60
|
| Rate for Payer: Humana ChoiceCare |
$1.50
|
| Rate for Payer: Humana Medicare |
$0.56
|
| Rate for Payer: Lucent All Commercial |
$0.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.56
|
| Rate for Payer: PHCS All Commercial |
$1.30
|
| Rate for Payer: PHP All Commercial |
$1.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.68
|
| Rate for Payer: Sagamore Health Network All Products |
$1.34
|
| Rate for Payer: Signature Care EPO |
$1.44
|
| Rate for Payer: Signature Care PPO |
$1.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.37
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
|
|
OXYCODONE 10 MG ORAL TR12
|
Facility
|
OP
|
$32.07
|
|
|
Service Code
|
NDC 59011041020
|
| Hospital Charge Code |
171241
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.94 |
| Max. Negotiated Rate |
$29.82 |
| Rate for Payer: Aetna Commercial |
$27.06
|
| Rate for Payer: Aetna Medicare |
$10.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$18.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.29
|
| Rate for Payer: Cash Price |
$19.24
|
| Rate for Payer: Centivo All Commercial |
$17.44
|
| Rate for Payer: Cigna All Commercial |
$27.67
|
| Rate for Payer: CORVEL All Commercial |
$29.82
|
| Rate for Payer: Coventry All Commercial |
$28.22
|
| Rate for Payer: Encore All Commercial |
$29.52
|
| Rate for Payer: Frontpath All Commercial |
$29.50
|
| Rate for Payer: Humana ChoiceCare |
$27.70
|
| Rate for Payer: Humana Medicare |
$10.26
|
| Rate for Payer: Lucent All Commercial |
$17.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.86
|
| Rate for Payer: PHCS All Commercial |
$24.05
|
| Rate for Payer: PHP All Commercial |
$24.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.51
|
| Rate for Payer: Sagamore Health Network All Products |
$24.76
|
| Rate for Payer: Signature Care EPO |
$26.62
|
| Rate for Payer: Signature Care PPO |
$28.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27.26
|
| Rate for Payer: United Healthcare Commercial |
$25.27
|
| Rate for Payer: United Healthcare Medicare |
$10.26
|
|
|
OXYCODONE 10 MG ORAL TR12
|
Facility
|
IP
|
$32.07
|
|
|
Service Code
|
NDC 59011041020
|
| Hospital Charge Code |
171241
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.05 |
| Max. Negotiated Rate |
$29.82 |
| Rate for Payer: Aetna Commercial |
$27.71
|
| Rate for Payer: Cash Price |
$19.24
|
| Rate for Payer: Cigna All Commercial |
$27.67
|
| Rate for Payer: CORVEL All Commercial |
$29.82
|
| Rate for Payer: Coventry All Commercial |
$28.22
|
| Rate for Payer: Encore All Commercial |
$29.52
|
| Rate for Payer: Frontpath All Commercial |
$29.50
|
| Rate for Payer: Humana ChoiceCare |
$27.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.86
|
| Rate for Payer: PHCS All Commercial |
$24.05
|
| Rate for Payer: PHP All Commercial |
$24.32
|
| Rate for Payer: Sagamore Health Network All Products |
$24.76
|
| Rate for Payer: Signature Care EPO |
$26.62
|
| Rate for Payer: Signature Care PPO |
$28.22
|
| Rate for Payer: United Healthcare Commercial |
$25.27
|
|
|
OXYCODONE 15 MG ORAL TAB
|
Facility
|
IP
|
$5.53
|
|
|
Service Code
|
NDC 00406851562
|
| Hospital Charge Code |
28899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.15 |
| Max. Negotiated Rate |
$5.14 |
| Rate for Payer: Aetna Commercial |
$4.78
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cigna All Commercial |
$4.77
|
| Rate for Payer: CORVEL All Commercial |
$5.14
|
| Rate for Payer: Coventry All Commercial |
$4.87
|
| Rate for Payer: Encore All Commercial |
$5.09
|
| Rate for Payer: Frontpath All Commercial |
$5.09
|
| Rate for Payer: Humana ChoiceCare |
$4.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.98
|
| Rate for Payer: PHCS All Commercial |
$4.15
|
| Rate for Payer: PHP All Commercial |
$4.19
|
| Rate for Payer: Sagamore Health Network All Products |
$4.27
|
| Rate for Payer: Signature Care EPO |
$4.59
|
| Rate for Payer: Signature Care PPO |
$4.87
|
| Rate for Payer: United Healthcare Commercial |
$4.36
|
|
|
OXYCODONE 15 MG ORAL TAB
|
Facility
|
OP
|
$5.53
|
|
|
Service Code
|
NDC 00406851562
|
| Hospital Charge Code |
28899
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$5.14 |
| Rate for Payer: Aetna Commercial |
$4.67
|
| Rate for Payer: Aetna Medicare |
$1.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.46
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.95
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Centivo All Commercial |
$3.01
|
| Rate for Payer: Cigna All Commercial |
$4.77
|
| Rate for Payer: CORVEL All Commercial |
$5.14
|
| Rate for Payer: Coventry All Commercial |
$4.87
|
| Rate for Payer: Encore All Commercial |
$5.09
|
| Rate for Payer: Frontpath All Commercial |
$5.09
|
| Rate for Payer: Humana ChoiceCare |
$4.78
|
| Rate for Payer: Humana Medicare |
$1.77
|
| Rate for Payer: Lucent All Commercial |
$3.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.98
|
| Rate for Payer: PHCS All Commercial |
$4.15
|
| Rate for Payer: PHP All Commercial |
$4.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.16
|
| Rate for Payer: Sagamore Health Network All Products |
$4.27
|
| Rate for Payer: Signature Care EPO |
$4.59
|
| Rate for Payer: Signature Care PPO |
$4.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.70
|
| Rate for Payer: United Healthcare Commercial |
$4.36
|
| Rate for Payer: United Healthcare Medicare |
$1.77
|
|
|
OXYCODONE 40 MG ORAL TR12
|
Facility
|
IP
|
$102.27
|
|
|
Service Code
|
NDC 59011044020
|
| Hospital Charge Code |
171245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.70 |
| Max. Negotiated Rate |
$95.11 |
| Rate for Payer: Aetna Commercial |
$88.36
|
| Rate for Payer: Cash Price |
$61.36
|
| Rate for Payer: Cigna All Commercial |
$88.26
|
| Rate for Payer: CORVEL All Commercial |
$95.11
|
| Rate for Payer: Coventry All Commercial |
$90.00
|
| Rate for Payer: Encore All Commercial |
$94.14
|
| Rate for Payer: Frontpath All Commercial |
$94.09
|
| Rate for Payer: Humana ChoiceCare |
$88.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$92.04
|
| Rate for Payer: PHCS All Commercial |
$76.70
|
| Rate for Payer: PHP All Commercial |
$77.56
|
| Rate for Payer: Sagamore Health Network All Products |
$78.95
|
| Rate for Payer: Signature Care EPO |
$84.88
|
| Rate for Payer: Signature Care PPO |
$90.00
|
| Rate for Payer: United Healthcare Commercial |
$80.59
|
|
