|
PALIPERIDONE PALMITATE 234 MG/1.5 ML IM SYRG
|
Facility
|
OP
|
$11,477.06
|
|
|
Service Code
|
HCPCS J2426
|
| Hospital Charge Code |
108109
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.01 |
| Max. Negotiated Rate |
$10,673.67 |
| Rate for Payer: Aetna Commercial |
$9,686.64
|
| Rate for Payer: Aetna Medicare |
$3,672.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$16.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,557.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6,591.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7,174.31
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$16.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,223.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,039.93
|
| Rate for Payer: Cash Price |
$6,886.24
|
| Rate for Payer: Cash Price |
$6,886.24
|
| Rate for Payer: Centivo All Commercial |
$6,243.52
|
| Rate for Payer: Cigna All Commercial |
$9,904.70
|
| Rate for Payer: CORVEL All Commercial |
$10,673.67
|
| Rate for Payer: Coventry All Commercial |
$10,099.81
|
| Rate for Payer: Encore All Commercial |
$10,564.64
|
| Rate for Payer: Frontpath All Commercial |
$10,558.90
|
| Rate for Payer: Humana ChoiceCare |
$9,912.74
|
| Rate for Payer: Humana Medicare |
$3,672.66
|
| Rate for Payer: Lucent All Commercial |
$6,243.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,329.36
|
| Rate for Payer: Managed Health Services Medicaid |
$16.01
|
| Rate for Payer: MDWise Medicaid |
$16.01
|
| Rate for Payer: PHCS All Commercial |
$8,607.80
|
| Rate for Payer: PHP All Commercial |
$8,704.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,476.05
|
| Rate for Payer: Sagamore Health Network All Products |
$8,860.29
|
| Rate for Payer: Signature Care EPO |
$9,525.96
|
| Rate for Payer: Signature Care PPO |
$10,099.81
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9,755.50
|
| Rate for Payer: United Healthcare Commercial |
$9,043.92
|
| Rate for Payer: United Healthcare Medicare |
$3,672.66
|
|
|
PALIPERIDONE PALMITATE 234 MG/1.5 ML IM SYRG
|
Facility
|
IP
|
$11,477.06
|
|
|
Service Code
|
HCPCS J2426
|
| Hospital Charge Code |
108109
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,607.80 |
| Max. Negotiated Rate |
$10,673.67 |
| Rate for Payer: Aetna Commercial |
$9,916.18
|
| Rate for Payer: Cash Price |
$6,886.24
|
| Rate for Payer: Cigna All Commercial |
$9,904.70
|
| Rate for Payer: CORVEL All Commercial |
$10,673.67
|
| Rate for Payer: Coventry All Commercial |
$10,099.81
|
| Rate for Payer: Encore All Commercial |
$10,564.64
|
| Rate for Payer: Frontpath All Commercial |
$10,558.90
|
| Rate for Payer: Humana ChoiceCare |
$9,912.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,329.36
|
| Rate for Payer: PHCS All Commercial |
$8,607.80
|
| Rate for Payer: PHP All Commercial |
$8,704.20
|
| Rate for Payer: Sagamore Health Network All Products |
$8,860.29
|
| Rate for Payer: Signature Care EPO |
$9,525.96
|
| Rate for Payer: Signature Care PPO |
$10,099.81
|
| Rate for Payer: United Healthcare Commercial |
$9,043.92
|
|
|
PALIVIZUMAB 100 MG/ML IM SOLN
|
Facility
|
OP
|
$12,634.37
|
|
|
Service Code
|
HCPCS 90378
|
| Hospital Charge Code |
41675
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,916.65 |
| Max. Negotiated Rate |
$11,749.96 |
| Rate for Payer: Aetna Commercial |
$10,663.41
|
| Rate for Payer: Aetna Medicare |
$4,043.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,916.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7,255.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7,897.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,649.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,447.30
|
| Rate for Payer: Cash Price |
$7,580.62
|
| Rate for Payer: Centivo All Commercial |
$6,873.10
|
| Rate for Payer: Cigna All Commercial |
$10,903.46
|
| Rate for Payer: CORVEL All Commercial |
$11,749.96
|
| Rate for Payer: Coventry All Commercial |
$11,118.25
|
| Rate for Payer: Encore All Commercial |
$11,629.94
|
| Rate for Payer: Frontpath All Commercial |
$11,623.62
|
| Rate for Payer: Humana ChoiceCare |
$10,912.31
|
| Rate for Payer: Humana Medicare |
$4,043.00
|
| Rate for Payer: Lucent All Commercial |
$6,873.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11,370.93
|
| Rate for Payer: PHCS All Commercial |
$9,475.78
|
| Rate for Payer: PHP All Commercial |
$9,581.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,927.40
|
| Rate for Payer: Sagamore Health Network All Products |
$9,753.73
|
| Rate for Payer: Signature Care EPO |
$10,486.53
|
| Rate for Payer: Signature Care PPO |
$11,118.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$10,739.21
|
| Rate for Payer: United Healthcare Commercial |
$9,955.88
|
| Rate for Payer: United Healthcare Medicare |
$4,043.00
|
|
|
PALIVIZUMAB 100 MG/ML IM SOLN
|
Facility
|
IP
|
$12,634.37
|
|
|
Service Code
|
HCPCS 90378
|
| Hospital Charge Code |
41675
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9,475.78 |
| Max. Negotiated Rate |
$11,749.96 |
| Rate for Payer: Aetna Commercial |
$10,916.10
|
| Rate for Payer: Cash Price |
$7,580.62
|
| Rate for Payer: Cigna All Commercial |
$10,903.46
|
| Rate for Payer: CORVEL All Commercial |
$11,749.96
|
| Rate for Payer: Coventry All Commercial |
$11,118.25
|
| Rate for Payer: Encore All Commercial |
$11,629.94
|
| Rate for Payer: Frontpath All Commercial |
$11,623.62
|
| Rate for Payer: Humana ChoiceCare |
$10,912.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11,370.93
|
| Rate for Payer: PHCS All Commercial |
$9,475.78
|
| Rate for Payer: PHP All Commercial |
$9,581.91
|
| Rate for Payer: Sagamore Health Network All Products |
$9,753.73
|
| Rate for Payer: Signature Care EPO |
$10,486.53
|
| Rate for Payer: Signature Care PPO |
$11,118.25
|
| Rate for Payer: United Healthcare Commercial |
$9,955.88
|
|
|
PANTOPRAZOLE 40 MG IV SOLR
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
26226
|
|
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
|
|
|
PANTOPRAZOLE 40 MG IV SOLR
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
26226
|
|
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
|
|
|
PANTOPRAZOLE 40 MG ORAL GRPS
|
Facility
|
OP
|
$47.91
|
|
|
Service Code
|
NDC 62756007164
|
| Hospital Charge Code |
89791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.85 |
| Max. Negotiated Rate |
$44.55 |
| Rate for Payer: Aetna Commercial |
$40.43
|
| Rate for Payer: Aetna Medicare |
$15.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$27.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.86
|
| Rate for Payer: Cash Price |
$28.74
|
| Rate for Payer: Centivo All Commercial |
$26.06
|
| Rate for Payer: Cigna All Commercial |
$41.34
|
| Rate for Payer: CORVEL All Commercial |
$44.55
|
| Rate for Payer: Coventry All Commercial |
$42.16
|
| Rate for Payer: Encore All Commercial |
$44.10
|
| Rate for Payer: Frontpath All Commercial |
$44.08
|
| Rate for Payer: Humana ChoiceCare |
$41.38
|
| Rate for Payer: Humana Medicare |
$15.33
|
| Rate for Payer: Lucent All Commercial |
$26.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.12
|
| Rate for Payer: PHCS All Commercial |
$35.93
|
| Rate for Payer: PHP All Commercial |
$36.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.68
|
| Rate for Payer: Sagamore Health Network All Products |
$36.98
|
| Rate for Payer: Signature Care EPO |
$39.76
|
| Rate for Payer: Signature Care PPO |
$42.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.72
|
| Rate for Payer: United Healthcare Commercial |
$37.75
|
| Rate for Payer: United Healthcare Medicare |
$15.33
|
|
|
PANTOPRAZOLE 40 MG ORAL GRPS
|
Facility
|
IP
|
$47.91
|
|
|
Service Code
|
NDC 62756007164
|
| Hospital Charge Code |
89791
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.93 |
| Max. Negotiated Rate |
$44.55 |
| Rate for Payer: Aetna Commercial |
$41.39
|
| Rate for Payer: Cash Price |
$28.74
|
| Rate for Payer: Cigna All Commercial |
$41.34
|
| Rate for Payer: CORVEL All Commercial |
$44.55
|
| Rate for Payer: Coventry All Commercial |
$42.16
|
| Rate for Payer: Encore All Commercial |
$44.10
|
| Rate for Payer: Frontpath All Commercial |
$44.08
|
| Rate for Payer: Humana ChoiceCare |
$41.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.12
|
| Rate for Payer: PHCS All Commercial |
$35.93
|
| Rate for Payer: PHP All Commercial |
$36.33
|
| Rate for Payer: Sagamore Health Network All Products |
$36.98
|
| Rate for Payer: Signature Care EPO |
$39.76
|
| Rate for Payer: Signature Care PPO |
$42.16
|
| Rate for Payer: United Healthcare Commercial |
$37.75
|
|
|
PANTOPRAZOLE 40 MG ORAL TBEC
|
Facility
|
IP
|
$1.52
|
|
|
Service Code
|
NDC 00904647461
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna Commercial |
$1.31
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cigna All Commercial |
$1.31
|
| Rate for Payer: CORVEL All Commercial |
$1.41
|
| Rate for Payer: Coventry All Commercial |
$1.34
|
| Rate for Payer: Encore All Commercial |
$1.40
|
| Rate for Payer: Frontpath All Commercial |
$1.40
|
| Rate for Payer: Humana ChoiceCare |
$1.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.37
|
| Rate for Payer: PHCS All Commercial |
$1.14
|
| Rate for Payer: PHP All Commercial |
$1.15
|
| Rate for Payer: Sagamore Health Network All Products |
$1.17
|
| Rate for Payer: Signature Care EPO |
$1.26
|
| Rate for Payer: Signature Care PPO |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
|
|
PANTOPRAZOLE 40 MG ORAL TBEC
|
Facility
|
OP
|
$1.52
|
|
|
Service Code
|
NDC 00904647461
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna Commercial |
$1.28
|
| Rate for Payer: Aetna Medicare |
$0.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.53
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Centivo All Commercial |
$0.83
|
| Rate for Payer: Cigna All Commercial |
$1.31
|
| Rate for Payer: CORVEL All Commercial |
$1.41
|
| Rate for Payer: Coventry All Commercial |
$1.34
|
| Rate for Payer: Encore All Commercial |
$1.40
|
| Rate for Payer: Frontpath All Commercial |
$1.40
|
| Rate for Payer: Humana ChoiceCare |
$1.31
|
| Rate for Payer: Humana Medicare |
$0.49
|
| Rate for Payer: Lucent All Commercial |
$0.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.37
|
| Rate for Payer: PHCS All Commercial |
$1.14
|
| Rate for Payer: PHP All Commercial |
$1.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.59
|
| Rate for Payer: Sagamore Health Network All Products |
$1.17
|
| Rate for Payer: Signature Care EPO |
$1.26
|
| Rate for Payer: Signature Care PPO |
$1.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.29
|
| Rate for Payer: United Healthcare Commercial |
$1.20
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
|
|
PARENTERAL NUTRITION (CAMERON)
|
Facility
|
IP
|
$1,072.00
|
|
|
Service Code
|
NDC 099999993
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$804.00 |
| Max. Negotiated Rate |
$996.96 |
| Rate for Payer: Aetna Commercial |
$926.21
|
| Rate for Payer: Cash Price |
$643.20
|
| Rate for Payer: Cigna All Commercial |
$925.14
|
| Rate for Payer: CORVEL All Commercial |
$996.96
|
| Rate for Payer: Coventry All Commercial |
$943.36
|
| Rate for Payer: Encore All Commercial |
$986.78
|
| Rate for Payer: Frontpath All Commercial |
$986.24
|
| Rate for Payer: Humana ChoiceCare |
$925.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$964.80
|
| Rate for Payer: PHCS All Commercial |
$804.00
|
| Rate for Payer: PHP All Commercial |
$813.00
|
| Rate for Payer: Sagamore Health Network All Products |
$827.58
|
| Rate for Payer: Signature Care EPO |
$889.76
|
| Rate for Payer: Signature Care PPO |
$943.36
|
| Rate for Payer: United Healthcare Commercial |
$844.74
|
|
|
PARENTERAL NUTRITION (CAMERON)
|
Facility
|
OP
|
$1,072.00
|
|
|
Service Code
|
NDC 099999993
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$996.96 |
| Rate for Payer: Aetna Commercial |
$904.77
|
| Rate for Payer: Aetna Medicare |
$343.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$332.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$615.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$670.11
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$394.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$377.34
|
| Rate for Payer: Cash Price |
$643.20
|
| Rate for Payer: Cash Price |
$643.20
|
| Rate for Payer: Centivo All Commercial |
$583.17
|
| Rate for Payer: Cigna All Commercial |
$925.14
|
| Rate for Payer: CORVEL All Commercial |
$996.96
|
| Rate for Payer: Coventry All Commercial |
$943.36
|
| Rate for Payer: Encore All Commercial |
$986.78
|
| Rate for Payer: Frontpath All Commercial |
$986.24
|
| Rate for Payer: Humana ChoiceCare |
$925.89
|
| Rate for Payer: Humana Medicare |
$343.04
|
| Rate for Payer: Lucent All Commercial |
$583.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$964.80
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$804.00
|
| Rate for Payer: PHP All Commercial |
$813.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$418.08
|
| Rate for Payer: Sagamore Health Network All Products |
$827.58
|
| Rate for Payer: Signature Care EPO |
$889.76
|
| Rate for Payer: Signature Care PPO |
$943.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$911.20
|
| Rate for Payer: United Healthcare Commercial |
$844.74
|
| Rate for Payer: United Healthcare Medicare |
$343.04
|
|
|
PARENTERAL NUTRITION (CAMERON)
|
Facility
|
OP
|
$1,008.00
|
|
|
Service Code
|
NDC 099999995
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$937.44 |
| Rate for Payer: Aetna Commercial |
$850.75
|
| Rate for Payer: Aetna Medicare |
$322.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$312.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$578.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$630.10
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$370.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$354.82
|
| Rate for Payer: Cash Price |
$604.80
|
| Rate for Payer: Cash Price |
$604.80
|
| Rate for Payer: Centivo All Commercial |
$548.35
|
| Rate for Payer: Cigna All Commercial |
$869.90
|
| Rate for Payer: CORVEL All Commercial |
$937.44
|
| Rate for Payer: Coventry All Commercial |
$887.04
|
| Rate for Payer: Encore All Commercial |
$927.86
|
| Rate for Payer: Frontpath All Commercial |
$927.36
|
| Rate for Payer: Humana ChoiceCare |
$870.61
|
| Rate for Payer: Humana Medicare |
$322.56
|
| Rate for Payer: Lucent All Commercial |
$548.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$907.20
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$756.00
|
| Rate for Payer: PHP All Commercial |
$764.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$393.12
|
| Rate for Payer: Sagamore Health Network All Products |
$778.18
|
| Rate for Payer: Signature Care EPO |
$836.64
|
| Rate for Payer: Signature Care PPO |
$887.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$856.80
|
| Rate for Payer: United Healthcare Commercial |
$794.30
|
| Rate for Payer: United Healthcare Medicare |
$322.56
|
|
|
PARENTERAL NUTRITION (CAMERON)
|
Facility
|
OP
|
$1,020.00
|
|
|
Service Code
|
NDC 099999994
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$948.60 |
| Rate for Payer: Aetna Commercial |
$860.88
|
| Rate for Payer: Aetna Medicare |
$326.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$316.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$585.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$637.60
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$375.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$359.04
|
| Rate for Payer: Cash Price |
$612.00
|
| Rate for Payer: Cash Price |
$612.00
|
| Rate for Payer: Centivo All Commercial |
$554.88
|
| Rate for Payer: Cigna All Commercial |
$880.26
|
| Rate for Payer: CORVEL All Commercial |
$948.60
|
| Rate for Payer: Coventry All Commercial |
$897.60
|
| Rate for Payer: Encore All Commercial |
$938.91
|
| Rate for Payer: Frontpath All Commercial |
$938.40
|
| Rate for Payer: Humana ChoiceCare |
$880.97
|
| Rate for Payer: Humana Medicare |
$326.40
|
| Rate for Payer: Lucent All Commercial |
$554.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$918.00
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$765.00
|
| Rate for Payer: PHP All Commercial |
$773.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$397.80
|
| Rate for Payer: Sagamore Health Network All Products |
$787.44
|
| Rate for Payer: Signature Care EPO |
$846.60
|
| Rate for Payer: Signature Care PPO |
$897.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$867.00
|
| Rate for Payer: United Healthcare Commercial |
$803.76
|
| Rate for Payer: United Healthcare Medicare |
$326.40
|
|
|
PARENTERAL NUTRITION (CAMERON)
|
Facility
|
IP
|
$1,020.00
|
|
|
Service Code
|
NDC 099999994
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$765.00 |
| Max. Negotiated Rate |
$948.60 |
| Rate for Payer: Aetna Commercial |
$881.28
|
| Rate for Payer: Cash Price |
$612.00
|
| Rate for Payer: Cigna All Commercial |
$880.26
|
| Rate for Payer: CORVEL All Commercial |
$948.60
|
| Rate for Payer: Coventry All Commercial |
$897.60
|
| Rate for Payer: Encore All Commercial |
$938.91
|
| Rate for Payer: Frontpath All Commercial |
$938.40
|
| Rate for Payer: Humana ChoiceCare |
$880.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$918.00
|
| Rate for Payer: PHCS All Commercial |
$765.00
|
| Rate for Payer: PHP All Commercial |
$773.57
|
| Rate for Payer: Sagamore Health Network All Products |
$787.44
|
| Rate for Payer: Signature Care EPO |
$846.60
|
| Rate for Payer: Signature Care PPO |
$897.60
|
| Rate for Payer: United Healthcare Commercial |
$803.76
|
|
|
PARENTERAL NUTRITION (CAMERON)
|
Facility
|
IP
|
$1,008.00
|
|
|
Service Code
|
NDC 099999995
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$756.00 |
| Max. Negotiated Rate |
$937.44 |
| Rate for Payer: Aetna Commercial |
$870.91
|
| Rate for Payer: Cash Price |
$604.80
|
| Rate for Payer: Cigna All Commercial |
$869.90
|
| Rate for Payer: CORVEL All Commercial |
$937.44
|
| Rate for Payer: Coventry All Commercial |
$887.04
|
| Rate for Payer: Encore All Commercial |
$927.86
|
| Rate for Payer: Frontpath All Commercial |
$927.36
|
| Rate for Payer: Humana ChoiceCare |
$870.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$907.20
|
| Rate for Payer: PHCS All Commercial |
$756.00
|
| Rate for Payer: PHP All Commercial |
$764.47
|
| Rate for Payer: Sagamore Health Network All Products |
$778.18
|
| Rate for Payer: Signature Care EPO |
$836.64
|
| Rate for Payer: Signature Care PPO |
$887.04
|
| Rate for Payer: United Healthcare Commercial |
$794.30
|
|
|
PAROXETINE HCL 20 MG ORAL TAB
|
Facility
|
OP
|
$1.37
|
|
|
Service Code
|
NDC 00904567761
|
| Hospital Charge Code |
10855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Aetna Commercial |
$1.15
|
| Rate for Payer: Aetna Medicare |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.48
|
| Rate for Payer: Cash Price |
$0.82
|
| Rate for Payer: Centivo All Commercial |
$0.74
|
| Rate for Payer: Cigna All Commercial |
$1.18
|
| Rate for Payer: CORVEL All Commercial |
$1.27
|
| Rate for Payer: Coventry All Commercial |
$1.20
|
| Rate for Payer: Encore All Commercial |
$1.26
|
| Rate for Payer: Frontpath All Commercial |
$1.26
|
| Rate for Payer: Humana ChoiceCare |
$1.18
|
| Rate for Payer: Humana Medicare |
$0.44
|
| Rate for Payer: Lucent All Commercial |
$0.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.23
|
| Rate for Payer: PHCS All Commercial |
$1.02
|
| Rate for Payer: PHP All Commercial |
$1.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.53
|
| Rate for Payer: Sagamore Health Network All Products |
$1.05
|
| Rate for Payer: Signature Care EPO |
$1.13
|
| Rate for Payer: Signature Care PPO |
$1.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.08
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
|
|
PAROXETINE HCL 20 MG ORAL TAB
|
Facility
|
IP
|
$1.37
|
|
|
Service Code
|
NDC 00904567761
|
| Hospital Charge Code |
10855
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Aetna Commercial |
$1.18
|
| Rate for Payer: Cash Price |
$0.82
|
| Rate for Payer: Cigna All Commercial |
$1.18
|
| Rate for Payer: CORVEL All Commercial |
$1.27
|
| Rate for Payer: Coventry All Commercial |
$1.20
|
| Rate for Payer: Encore All Commercial |
$1.26
|
| Rate for Payer: Frontpath All Commercial |
$1.26
|
| Rate for Payer: Humana ChoiceCare |
$1.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.23
|
| Rate for Payer: PHCS All Commercial |
$1.02
|
| Rate for Payer: PHP All Commercial |
$1.04
|
| Rate for Payer: Sagamore Health Network All Products |
$1.05
|
| Rate for Payer: Signature Care EPO |
$1.13
|
| Rate for Payer: Signature Care PPO |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$1.08
|
|
|
PARTIAL THICKNESS BURNS W/O SKIN GRAFT
|
Facility
|
IP
|
$6,138.35
|
|
|
Service Code
|
APR-DRG 8443
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$6,138.35 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$855.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$855.00
|
| Rate for Payer: Managed Health Services Medicaid |
$855.00
|
| Rate for Payer: MDWise Medicaid |
$855.00
|
|
|
PARTIAL THICKNESS BURNS W/O SKIN GRAFT
|
Facility
|
IP
|
$2,334.30
|
|
|
Service Code
|
APR-DRG 8441
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$2,334.30 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$855.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$855.00
|
| Rate for Payer: Managed Health Services Medicaid |
$855.00
|
| Rate for Payer: MDWise Medicaid |
$855.00
|
|
|
PARTIAL THICKNESS BURNS W/O SKIN GRAFT
|
Facility
|
IP
|
$3,933.73
|
|
|
Service Code
|
APR-DRG 8442
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$3,933.73 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$855.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$855.00
|
| Rate for Payer: Managed Health Services Medicaid |
$855.00
|
| Rate for Payer: MDWise Medicaid |
$855.00
|
|
|
PARTIAL THICKNESS BURNS W/O SKIN GRAFT
|
Facility
|
IP
|
$10,979.86
|
|
|
Service Code
|
APR-DRG 8444
|
| Min. Negotiated Rate |
$855.00 |
| Max. Negotiated Rate |
$10,979.86 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$855.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$855.00
|
| Rate for Payer: Managed Health Services Medicaid |
$855.00
|
| Rate for Payer: MDWise Medicaid |
$855.00
|
|
|
PATIENT SUPPLIED MEDICATION
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00000004370
|
| Hospital Charge Code |
900006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| 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 |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| 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 |
$0.32
|
|
|
PATIENT SUPPLIED MEDICATION
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00000004370
|
| Hospital Charge Code |
900006
|
|
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 |
$0.60
|
| 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
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1-0.2-0.2 % OPHT DROP
|
Facility
|
OP
|
$14.81
|
|
|
Service Code
|
NDC 57896018105
|
| Hospital Charge Code |
41412
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$13.77 |
| Rate for Payer: Aetna Commercial |
$12.50
|
| Rate for Payer: Aetna Medicare |
$4.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.21
|
| Rate for Payer: Cash Price |
$8.88
|
| Rate for Payer: Cash Price |
$8.88
|
| Rate for Payer: Centivo All Commercial |
$8.05
|
| Rate for Payer: Cigna All Commercial |
$12.78
|
| Rate for Payer: CORVEL All Commercial |
$13.77
|
| Rate for Payer: Coventry All Commercial |
$13.03
|
| Rate for Payer: Encore All Commercial |
$13.63
|
| Rate for Payer: Frontpath All Commercial |
$13.62
|
| Rate for Payer: Humana ChoiceCare |
$12.79
|
| Rate for Payer: Humana Medicare |
$4.74
|
| Rate for Payer: Lucent All Commercial |
$8.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.32
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$11.10
|
| Rate for Payer: PHP All Commercial |
$11.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.77
|
| Rate for Payer: Sagamore Health Network All Products |
$11.43
|
| Rate for Payer: Signature Care EPO |
$12.29
|
| Rate for Payer: Signature Care PPO |
$13.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.58
|
| Rate for Payer: United Healthcare Commercial |
$11.67
|
| Rate for Payer: United Healthcare Medicare |
$4.74
|
|
