|
OXYCODONE 5 MG ORAL TAB
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904696661
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.04
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$2.04
|
| Rate for Payer: Lucent All Commercial |
$2.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.32
|
|
|
OXYCODONE 80 MG ORAL TR12
|
Facility
OP
|
$170.00
|
|
|
Service Code
|
NDC 59011048020
|
| Hospital Charge Code |
171247
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$158.10 |
| Rate for Payer: Aetna Commercial |
$143.48
|
| Rate for Payer: Aetna Medicare |
$56.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$56.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$97.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$106.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$64.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$61.71
|
| Rate for Payer: Cash Price |
$105.40
|
| Rate for Payer: Centivo All Commercial |
$86.70
|
| Rate for Payer: Cigna All Commercial |
$146.71
|
| Rate for Payer: CORVEL All Commercial |
$158.10
|
| Rate for Payer: Coventry All Commercial |
$149.60
|
| Rate for Payer: Encore All Commercial |
$156.49
|
| Rate for Payer: Frontpath All Commercial |
$156.40
|
| Rate for Payer: Humana ChoiceCare |
$146.83
|
| Rate for Payer: Humana Medicare |
$86.70
|
| Rate for Payer: Lucent All Commercial |
$86.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$153.00
|
| Rate for Payer: PHCS All Commercial |
$127.50
|
| Rate for Payer: PHP All Commercial |
$128.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$66.30
|
| Rate for Payer: Sagamore Health Network All Products |
$131.24
|
| Rate for Payer: Signature Care EPO |
$141.10
|
| Rate for Payer: Signature Care PPO |
$149.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$144.50
|
| Rate for Payer: United Healthcare Commercial |
$133.96
|
| Rate for Payer: United Healthcare Medicare |
$56.10
|
|
|
OXYCODONE 80 MG ORAL TR12
|
Facility
IP
|
$170.00
|
|
|
Service Code
|
NDC 59011048020
|
| Hospital Charge Code |
171247
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$158.10 |
| Rate for Payer: Aetna Commercial |
$146.88
|
| Rate for Payer: Cash Price |
$105.40
|
| Rate for Payer: Cigna All Commercial |
$146.71
|
| Rate for Payer: CORVEL All Commercial |
$158.10
|
| Rate for Payer: Coventry All Commercial |
$149.60
|
| Rate for Payer: Encore All Commercial |
$156.49
|
| Rate for Payer: Frontpath All Commercial |
$156.40
|
| Rate for Payer: Humana ChoiceCare |
$146.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$153.00
|
| Rate for Payer: PHCS All Commercial |
$127.50
|
| Rate for Payer: PHP All Commercial |
$128.93
|
| Rate for Payer: Sagamore Health Network All Products |
$131.24
|
| Rate for Payer: Signature Care EPO |
$141.10
|
| Rate for Payer: Signature Care PPO |
$149.60
|
| Rate for Payer: United Healthcare Commercial |
$133.96
|
|
|
OXYCODONE-ACETAMINOPHEN 10-325 MG ORAL TAB
|
Facility
OP
|
$7.88
|
|
|
Service Code
|
NDC 00904709561
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$7.33 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Medicare |
$2.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.86
|
| Rate for Payer: Cash Price |
$4.89
|
| Rate for Payer: Centivo All Commercial |
$4.02
|
| Rate for Payer: Cigna All Commercial |
$6.80
|
| Rate for Payer: CORVEL All Commercial |
$7.33
|
| Rate for Payer: Coventry All Commercial |
$6.94
|
| Rate for Payer: Encore All Commercial |
$7.26
|
| Rate for Payer: Frontpath All Commercial |
$7.25
|
| Rate for Payer: Humana ChoiceCare |
$6.81
|
| Rate for Payer: Humana Medicare |
$4.02
|
| Rate for Payer: Lucent All Commercial |
$4.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.09
|
| Rate for Payer: PHCS All Commercial |
$5.91
|
| Rate for Payer: PHP All Commercial |
$5.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.07
|
| Rate for Payer: Sagamore Health Network All Products |
$6.08
|
| Rate for Payer: Signature Care EPO |
$6.54
|
| Rate for Payer: Signature Care PPO |
$6.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.70
|
| Rate for Payer: United Healthcare Commercial |
$6.21
|
| Rate for Payer: United Healthcare Medicare |
$2.60
|
|
|
OXYCODONE-ACETAMINOPHEN 10-325 MG ORAL TAB
|
Facility
IP
|
$7.88
|
|
|
Service Code
|
NDC 00904709561
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.91 |
| Max. Negotiated Rate |
$7.33 |
| Rate for Payer: Aetna Commercial |
$6.81
|
| Rate for Payer: Cash Price |
$4.89
|
| Rate for Payer: Cigna All Commercial |
$6.80
|
| Rate for Payer: CORVEL All Commercial |
$7.33
|
| Rate for Payer: Coventry All Commercial |
$6.94
|
| Rate for Payer: Encore All Commercial |
$7.26
|
| Rate for Payer: Frontpath All Commercial |
$7.25
|
| Rate for Payer: Humana ChoiceCare |
$6.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.09
|
| Rate for Payer: PHCS All Commercial |
$5.91
|
| Rate for Payer: PHP All Commercial |
$5.98
|
| Rate for Payer: Sagamore Health Network All Products |
$6.08
|
| Rate for Payer: Signature Care EPO |
$6.54
|
| Rate for Payer: Signature Care PPO |
$6.94
|
| Rate for Payer: United Healthcare Commercial |
$6.21
|
|
|
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TAB
|
Facility
IP
|
$4.00
|
|
|
Service Code
|
NDC 00406051262
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TAB
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 00406051262
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.04
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$2.04
|
| Rate for Payer: Lucent All Commercial |
$2.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.32
|
|
|
OXYMETAZOLINE 0.05 % NASL SPRY
|
Facility
OP
|
$14.81
|
|
|
Service Code
|
NDC 00904743535
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.89 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$12.50
|
| Rate for Payer: Aetna Medicare |
$4.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.37
|
| Rate for Payer: Cash Price |
$9.18
|
| Rate for Payer: Cash Price |
$9.18
|
| Rate for Payer: Centivo All Commercial |
$7.55
|
| 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 |
$7.55
|
| Rate for Payer: Lucent All Commercial |
$7.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.32
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| 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 |
$4.89
|
|
|
OXYMETAZOLINE 0.05 % NASL SPRY
|
Facility
IP
|
$14.81
|
|
|
Service Code
|
NDC 00904743535
|
| Hospital Charge Code |
5943
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.10 |
| Max. Negotiated Rate |
$13.77 |
| Rate for Payer: Aetna Commercial |
$12.79
|
| Rate for Payer: Cash Price |
$9.18
|
| 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: Lutheran Preferred All Commercial |
$13.32
|
| Rate for Payer: PHCS All Commercial |
$11.10
|
| Rate for Payer: PHP All Commercial |
$11.23
|
| 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: United Healthcare Commercial |
$11.67
|
|
|
OXYTOCIN 10 UNITS/ML INJ SOLN
|
Facility
OP
|
$18.92
|
|
|
Service Code
|
HCPCS J2590
|
| Hospital Charge Code |
5944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$17.60 |
| Rate for Payer: Aetna Commercial |
$15.97
|
| Rate for Payer: Aetna Medicare |
$6.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.87
|
| Rate for Payer: Cash Price |
$11.73
|
| Rate for Payer: Centivo All Commercial |
$9.65
|
| Rate for Payer: Cigna All Commercial |
$16.33
|
| Rate for Payer: CORVEL All Commercial |
$17.60
|
| Rate for Payer: Coventry All Commercial |
$16.65
|
| Rate for Payer: Encore All Commercial |
$17.42
|
| Rate for Payer: Frontpath All Commercial |
$17.41
|
| Rate for Payer: Humana ChoiceCare |
$16.34
|
| Rate for Payer: Humana Medicare |
$9.65
|
| Rate for Payer: Lucent All Commercial |
$9.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.03
|
| Rate for Payer: PHCS All Commercial |
$14.19
|
| Rate for Payer: PHP All Commercial |
$14.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.38
|
| Rate for Payer: Sagamore Health Network All Products |
$14.61
|
| Rate for Payer: Signature Care EPO |
$15.70
|
| Rate for Payer: Signature Care PPO |
$16.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.08
|
| Rate for Payer: United Healthcare Commercial |
$14.91
|
| Rate for Payer: United Healthcare Medicare |
$6.24
|
|
|
OXYTOCIN 10 UNITS/ML INJ SOLN
|
Facility
IP
|
$18.92
|
|
|
Service Code
|
HCPCS J2590
|
| Hospital Charge Code |
5944
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.19 |
| Max. Negotiated Rate |
$17.60 |
| Rate for Payer: Aetna Commercial |
$16.35
|
| Rate for Payer: Cash Price |
$11.73
|
| Rate for Payer: Cigna All Commercial |
$16.33
|
| Rate for Payer: CORVEL All Commercial |
$17.60
|
| Rate for Payer: Coventry All Commercial |
$16.65
|
| Rate for Payer: Encore All Commercial |
$17.42
|
| Rate for Payer: Frontpath All Commercial |
$17.41
|
| Rate for Payer: Humana ChoiceCare |
$16.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.03
|
| Rate for Payer: PHCS All Commercial |
$14.19
|
| Rate for Payer: PHP All Commercial |
$14.35
|
| Rate for Payer: Sagamore Health Network All Products |
$14.61
|
| Rate for Payer: Signature Care EPO |
$15.70
|
| Rate for Payer: Signature Care PPO |
$16.65
|
| Rate for Payer: United Healthcare Commercial |
$14.91
|
|
|
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN
|
Facility
OP
|
$147.00
|
|
|
Service Code
|
HCPCS J2590
|
| Hospital Charge Code |
117335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.51 |
| Max. Negotiated Rate |
$136.71 |
| Rate for Payer: Aetna Commercial |
$124.07
|
| Rate for Payer: Aetna Medicare |
$48.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$48.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$84.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$91.89
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$55.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$53.36
|
| Rate for Payer: Cash Price |
$91.14
|
| Rate for Payer: Centivo All Commercial |
$74.97
|
| Rate for Payer: Cigna All Commercial |
$126.86
|
| Rate for Payer: CORVEL All Commercial |
$136.71
|
| Rate for Payer: Coventry All Commercial |
$129.36
|
| Rate for Payer: Encore All Commercial |
$135.31
|
| Rate for Payer: Frontpath All Commercial |
$135.24
|
| Rate for Payer: Humana ChoiceCare |
$126.96
|
| Rate for Payer: Humana Medicare |
$74.97
|
| Rate for Payer: Lucent All Commercial |
$74.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.30
|
| Rate for Payer: PHCS All Commercial |
$110.25
|
| Rate for Payer: PHP All Commercial |
$111.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$57.33
|
| Rate for Payer: Sagamore Health Network All Products |
$113.48
|
| Rate for Payer: Signature Care EPO |
$122.01
|
| Rate for Payer: Signature Care PPO |
$129.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$124.95
|
| Rate for Payer: United Healthcare Commercial |
$115.84
|
| Rate for Payer: United Healthcare Medicare |
$48.51
|
|
|
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN
|
Facility
IP
|
$147.00
|
|
|
Service Code
|
HCPCS J2590
|
| Hospital Charge Code |
117335
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$110.25 |
| Max. Negotiated Rate |
$136.71 |
| Rate for Payer: Aetna Commercial |
$127.01
|
| Rate for Payer: Cash Price |
$91.14
|
| Rate for Payer: Cigna All Commercial |
$126.86
|
| Rate for Payer: CORVEL All Commercial |
$136.71
|
| Rate for Payer: Coventry All Commercial |
$129.36
|
| Rate for Payer: Encore All Commercial |
$135.31
|
| Rate for Payer: Frontpath All Commercial |
$135.24
|
| Rate for Payer: Humana ChoiceCare |
$126.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.30
|
| Rate for Payer: PHCS All Commercial |
$110.25
|
| Rate for Payer: PHP All Commercial |
$111.48
|
| Rate for Payer: Sagamore Health Network All Products |
$113.48
|
| Rate for Payer: Signature Care EPO |
$122.01
|
| Rate for Payer: Signature Care PPO |
$129.36
|
| Rate for Payer: United Healthcare Commercial |
$115.84
|
|
|
PALIPERIDONE PALM (3 MONTH) 273 MG/0.88 ML IM SYRG
|
Facility
OP
|
$11,317.11
|
|
|
Service Code
|
HCPCS J2427
|
| Hospital Charge Code |
172862
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$10,524.91 |
| Rate for Payer: Aetna Commercial |
$9,551.64
|
| Rate for Payer: Aetna Medicare |
$3,734.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,734.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6,499.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7,074.32
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$12.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,294.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,108.11
|
| Rate for Payer: Cash Price |
$7,016.61
|
| Rate for Payer: Cash Price |
$7,016.61
|
| Rate for Payer: Centivo All Commercial |
$5,771.73
|
| Rate for Payer: Cigna All Commercial |
$9,766.67
|
| Rate for Payer: CORVEL All Commercial |
$10,524.91
|
| Rate for Payer: Coventry All Commercial |
$9,959.06
|
| Rate for Payer: Encore All Commercial |
$10,417.40
|
| Rate for Payer: Frontpath All Commercial |
$10,411.74
|
| Rate for Payer: Humana ChoiceCare |
$9,774.59
|
| Rate for Payer: Humana Medicare |
$5,771.73
|
| Rate for Payer: Lucent All Commercial |
$5,771.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,185.40
|
| Rate for Payer: Managed Health Services Medicaid |
$12.77
|
| Rate for Payer: MDWise Medicaid |
$12.77
|
| Rate for Payer: PHCS All Commercial |
$8,487.83
|
| Rate for Payer: PHP All Commercial |
$8,582.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,413.67
|
| Rate for Payer: Sagamore Health Network All Products |
$8,736.81
|
| Rate for Payer: Signature Care EPO |
$9,393.20
|
| Rate for Payer: Signature Care PPO |
$9,959.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9,619.54
|
| Rate for Payer: United Healthcare Commercial |
$8,917.88
|
| Rate for Payer: United Healthcare Medicare |
$3,734.65
|
|
|
PALIPERIDONE PALM (3 MONTH) 273 MG/0.88 ML IM SYRG
|
Facility
IP
|
$11,317.11
|
|
|
Service Code
|
HCPCS J2427
|
| Hospital Charge Code |
172862
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,487.83 |
| Max. Negotiated Rate |
$10,524.91 |
| Rate for Payer: Aetna Commercial |
$9,777.98
|
| Rate for Payer: Cash Price |
$7,016.61
|
| Rate for Payer: Cigna All Commercial |
$9,766.67
|
| Rate for Payer: CORVEL All Commercial |
$10,524.91
|
| Rate for Payer: Coventry All Commercial |
$9,959.06
|
| Rate for Payer: Encore All Commercial |
$10,417.40
|
| Rate for Payer: Frontpath All Commercial |
$10,411.74
|
| Rate for Payer: Humana ChoiceCare |
$9,774.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,185.40
|
| Rate for Payer: PHCS All Commercial |
$8,487.83
|
| Rate for Payer: PHP All Commercial |
$8,582.90
|
| Rate for Payer: Sagamore Health Network All Products |
$8,736.81
|
| Rate for Payer: Signature Care EPO |
$9,393.20
|
| Rate for Payer: Signature Care PPO |
$9,959.06
|
| Rate for Payer: United Healthcare Commercial |
$8,917.88
|
|
|
PALIPERIDONE PALM (3 MONTH) 410 MG/1.32 ML IM SYRG
|
Facility
IP
|
$17,105.57
|
|
|
Service Code
|
HCPCS J2427
|
| Hospital Charge Code |
172863
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12,829.18 |
| Max. Negotiated Rate |
$15,908.18 |
| Rate for Payer: Aetna Commercial |
$14,779.21
|
| Rate for Payer: Cash Price |
$10,605.45
|
| Rate for Payer: Cigna All Commercial |
$14,762.11
|
| Rate for Payer: CORVEL All Commercial |
$15,908.18
|
| Rate for Payer: Coventry All Commercial |
$15,052.90
|
| Rate for Payer: Encore All Commercial |
$15,745.68
|
| Rate for Payer: Frontpath All Commercial |
$15,737.12
|
| Rate for Payer: Humana ChoiceCare |
$14,774.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15,395.01
|
| Rate for Payer: PHCS All Commercial |
$12,829.18
|
| Rate for Payer: PHP All Commercial |
$12,972.86
|
| Rate for Payer: Sagamore Health Network All Products |
$13,205.50
|
| Rate for Payer: Signature Care EPO |
$14,197.62
|
| Rate for Payer: Signature Care PPO |
$15,052.90
|
| Rate for Payer: United Healthcare Commercial |
$13,479.19
|
|
|
PALIPERIDONE PALM (3 MONTH) 410 MG/1.32 ML IM SYRG
|
Facility
OP
|
$17,105.57
|
|
|
Service Code
|
HCPCS J2427
|
| Hospital Charge Code |
172863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$15,908.18 |
| Rate for Payer: Aetna Commercial |
$14,437.10
|
| Rate for Payer: Aetna Medicare |
$5,644.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,644.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9,823.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10,692.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$12.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6,491.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6,209.32
|
| Rate for Payer: Cash Price |
$10,605.45
|
| Rate for Payer: Cash Price |
$10,605.45
|
| Rate for Payer: Centivo All Commercial |
$8,723.84
|
| Rate for Payer: Cigna All Commercial |
$14,762.11
|
| Rate for Payer: CORVEL All Commercial |
$15,908.18
|
| Rate for Payer: Coventry All Commercial |
$15,052.90
|
| Rate for Payer: Encore All Commercial |
$15,745.68
|
| Rate for Payer: Frontpath All Commercial |
$15,737.12
|
| Rate for Payer: Humana ChoiceCare |
$14,774.08
|
| Rate for Payer: Humana Medicare |
$8,723.84
|
| Rate for Payer: Lucent All Commercial |
$8,723.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15,395.01
|
| Rate for Payer: Managed Health Services Medicaid |
$12.77
|
| Rate for Payer: MDWise Medicaid |
$12.77
|
| Rate for Payer: PHCS All Commercial |
$12,829.18
|
| Rate for Payer: PHP All Commercial |
$12,972.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,671.17
|
| Rate for Payer: Sagamore Health Network All Products |
$13,205.50
|
| Rate for Payer: Signature Care EPO |
$14,197.62
|
| Rate for Payer: Signature Care PPO |
$15,052.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$14,539.73
|
| Rate for Payer: United Healthcare Commercial |
$13,479.19
|
| Rate for Payer: United Healthcare Medicare |
$5,644.84
|
|
|
PALIPERIDONE PALM (3 MONTH) 546 MG/1.75 ML IM SYRG
|
Facility
IP
|
$22,635.45
|
|
|
Service Code
|
HCPCS J2427
|
| Hospital Charge Code |
172864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16,976.58 |
| Max. Negotiated Rate |
$21,050.96 |
| Rate for Payer: Aetna Commercial |
$19,557.03
|
| Rate for Payer: Cash Price |
$14,033.98
|
| Rate for Payer: Cigna All Commercial |
$19,534.39
|
| Rate for Payer: CORVEL All Commercial |
$21,050.96
|
| Rate for Payer: Coventry All Commercial |
$19,919.19
|
| Rate for Payer: Encore All Commercial |
$20,835.93
|
| Rate for Payer: Frontpath All Commercial |
$20,824.61
|
| Rate for Payer: Humana ChoiceCare |
$19,550.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20,371.90
|
| Rate for Payer: PHCS All Commercial |
$16,976.58
|
| Rate for Payer: PHP All Commercial |
$17,166.72
|
| Rate for Payer: Sagamore Health Network All Products |
$17,474.56
|
| Rate for Payer: Signature Care EPO |
$18,787.42
|
| Rate for Payer: Signature Care PPO |
$19,919.19
|
| Rate for Payer: United Healthcare Commercial |
$17,836.73
|
|
|
PALIPERIDONE PALM (3 MONTH) 546 MG/1.75 ML IM SYRG
|
Facility
OP
|
$22,635.45
|
|
|
Service Code
|
HCPCS J2427
|
| Hospital Charge Code |
172864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$21,050.96 |
| Rate for Payer: Aetna Commercial |
$19,104.32
|
| Rate for Payer: Aetna Medicare |
$7,469.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7,469.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$12,999.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14,149.42
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$12.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8,590.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8,216.67
|
| Rate for Payer: Cash Price |
$14,033.98
|
| Rate for Payer: Cash Price |
$14,033.98
|
| Rate for Payer: Centivo All Commercial |
$11,544.08
|
| Rate for Payer: Cigna All Commercial |
$19,534.39
|
| Rate for Payer: CORVEL All Commercial |
$21,050.96
|
| Rate for Payer: Coventry All Commercial |
$19,919.19
|
| Rate for Payer: Encore All Commercial |
$20,835.93
|
| Rate for Payer: Frontpath All Commercial |
$20,824.61
|
| Rate for Payer: Humana ChoiceCare |
$19,550.23
|
| Rate for Payer: Humana Medicare |
$11,544.08
|
| Rate for Payer: Lucent All Commercial |
$11,544.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20,371.90
|
| Rate for Payer: Managed Health Services Medicaid |
$12.77
|
| Rate for Payer: MDWise Medicaid |
$12.77
|
| Rate for Payer: PHCS All Commercial |
$16,976.58
|
| Rate for Payer: PHP All Commercial |
$17,166.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8,827.82
|
| Rate for Payer: Sagamore Health Network All Products |
$17,474.56
|
| Rate for Payer: Signature Care EPO |
$18,787.42
|
| Rate for Payer: Signature Care PPO |
$19,919.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$19,240.13
|
| Rate for Payer: United Healthcare Commercial |
$17,836.73
|
| Rate for Payer: United Healthcare Medicare |
$7,469.70
|
|
|
PALIPERIDONE PALM (3 MONTH) 819 MG/2.63 ML IM SYRG
|
Facility
OP
|
$34,081.94
|
|
|
Service Code
|
HCPCS J2427
|
| Hospital Charge Code |
172865
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$31,696.20 |
| Rate for Payer: Aetna Commercial |
$28,765.15
|
| Rate for Payer: Aetna Medicare |
$11,247.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11,247.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$19,573.26
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21,304.62
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$12.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12,934.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12,371.74
|
| Rate for Payer: Cash Price |
$21,130.80
|
| Rate for Payer: Cash Price |
$21,130.80
|
| Rate for Payer: Centivo All Commercial |
$17,381.79
|
| Rate for Payer: Cigna All Commercial |
$29,412.71
|
| Rate for Payer: CORVEL All Commercial |
$31,696.20
|
| Rate for Payer: Coventry All Commercial |
$29,992.10
|
| Rate for Payer: Encore All Commercial |
$31,372.42
|
| Rate for Payer: Frontpath All Commercial |
$31,355.38
|
| Rate for Payer: Humana ChoiceCare |
$29,436.57
|
| Rate for Payer: Humana Medicare |
$17,381.79
|
| Rate for Payer: Lucent All Commercial |
$17,381.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30,673.74
|
| Rate for Payer: Managed Health Services Medicaid |
$12.77
|
| Rate for Payer: MDWise Medicaid |
$12.77
|
| Rate for Payer: PHCS All Commercial |
$25,561.45
|
| Rate for Payer: PHP All Commercial |
$25,847.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13,291.96
|
| Rate for Payer: Sagamore Health Network All Products |
$26,311.25
|
| Rate for Payer: Signature Care EPO |
$28,288.01
|
| Rate for Payer: Signature Care PPO |
$29,992.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28,969.65
|
| Rate for Payer: United Healthcare Commercial |
$26,856.57
|
| Rate for Payer: United Healthcare Medicare |
$11,247.04
|
|
|
PALIPERIDONE PALM (3 MONTH) 819 MG/2.63 ML IM SYRG
|
Facility
IP
|
$34,081.94
|
|
|
Service Code
|
HCPCS J2427
|
| Hospital Charge Code |
172865
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25,561.45 |
| Max. Negotiated Rate |
$31,696.20 |
| Rate for Payer: Aetna Commercial |
$29,446.79
|
| Rate for Payer: Cash Price |
$21,130.80
|
| Rate for Payer: Cigna All Commercial |
$29,412.71
|
| Rate for Payer: CORVEL All Commercial |
$31,696.20
|
| Rate for Payer: Coventry All Commercial |
$29,992.10
|
| Rate for Payer: Encore All Commercial |
$31,372.42
|
| Rate for Payer: Frontpath All Commercial |
$31,355.38
|
| Rate for Payer: Humana ChoiceCare |
$29,436.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30,673.74
|
| Rate for Payer: PHCS All Commercial |
$25,561.45
|
| Rate for Payer: PHP All Commercial |
$25,847.74
|
| Rate for Payer: Sagamore Health Network All Products |
$26,311.25
|
| Rate for Payer: Signature Care EPO |
$28,288.01
|
| Rate for Payer: Signature Care PPO |
$29,992.10
|
| Rate for Payer: United Healthcare Commercial |
$26,856.57
|
|
|
PALIPERIDONE PALMITATE 156 MG/ML IM SYRG
|
Facility
OP
|
$7,545.16
|
|
|
Service Code
|
HCPCS J2426
|
| Hospital Charge Code |
99702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.02 |
| Max. Negotiated Rate |
$7,017.00 |
| Rate for Payer: Aetna Commercial |
$6,368.12
|
| Rate for Payer: Aetna Medicare |
$2,489.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,489.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4,333.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,716.48
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$15.02
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,863.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,738.89
|
| Rate for Payer: Cash Price |
$4,678.00
|
| Rate for Payer: Cash Price |
$4,678.00
|
| Rate for Payer: Centivo All Commercial |
$3,848.03
|
| Rate for Payer: Cigna All Commercial |
$6,511.47
|
| Rate for Payer: CORVEL All Commercial |
$7,017.00
|
| Rate for Payer: Coventry All Commercial |
$6,639.74
|
| Rate for Payer: Encore All Commercial |
$6,945.32
|
| Rate for Payer: Frontpath All Commercial |
$6,941.55
|
| Rate for Payer: Humana ChoiceCare |
$6,516.75
|
| Rate for Payer: Humana Medicare |
$3,848.03
|
| Rate for Payer: Lucent All Commercial |
$3,848.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,790.64
|
| Rate for Payer: Managed Health Services Medicaid |
$15.02
|
| Rate for Payer: MDWise Medicaid |
$15.02
|
| Rate for Payer: PHCS All Commercial |
$5,658.87
|
| Rate for Payer: PHP All Commercial |
$5,722.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,942.61
|
| Rate for Payer: Sagamore Health Network All Products |
$5,824.86
|
| Rate for Payer: Signature Care EPO |
$6,262.48
|
| Rate for Payer: Signature Care PPO |
$6,639.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,413.39
|
| Rate for Payer: United Healthcare Commercial |
$5,945.59
|
| Rate for Payer: United Healthcare Medicare |
$2,489.90
|
|
|
PALIPERIDONE PALMITATE 156 MG/ML IM SYRG
|
Facility
IP
|
$7,545.16
|
|
|
Service Code
|
HCPCS J2426
|
| Hospital Charge Code |
99702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,658.87 |
| Max. Negotiated Rate |
$7,017.00 |
| Rate for Payer: Aetna Commercial |
$6,519.02
|
| Rate for Payer: Cash Price |
$4,678.00
|
| Rate for Payer: Cigna All Commercial |
$6,511.47
|
| Rate for Payer: CORVEL All Commercial |
$7,017.00
|
| Rate for Payer: Coventry All Commercial |
$6,639.74
|
| Rate for Payer: Encore All Commercial |
$6,945.32
|
| Rate for Payer: Frontpath All Commercial |
$6,941.55
|
| Rate for Payer: Humana ChoiceCare |
$6,516.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,790.64
|
| Rate for Payer: PHCS All Commercial |
$5,658.87
|
| Rate for Payer: PHP All Commercial |
$5,722.25
|
| Rate for Payer: Sagamore Health Network All Products |
$5,824.86
|
| Rate for Payer: Signature Care EPO |
$6,262.48
|
| Rate for Payer: Signature Care PPO |
$6,639.74
|
| Rate for Payer: United Healthcare Commercial |
$5,945.59
|
|
|
PALIPERIDONE PALMITATE 234 MG/1.5 ML IM SYRG
|
Facility
OP
|
$11,317.46
|
|
|
Service Code
|
HCPCS J2426
|
| Hospital Charge Code |
108109
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.02 |
| Max. Negotiated Rate |
$10,525.24 |
| Rate for Payer: Aetna Commercial |
$9,551.94
|
| Rate for Payer: Aetna Medicare |
$3,734.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,734.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6,499.62
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7,074.55
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$15.02
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,294.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,108.24
|
| Rate for Payer: Cash Price |
$7,016.83
|
| Rate for Payer: Cash Price |
$7,016.83
|
| Rate for Payer: Centivo All Commercial |
$5,771.91
|
| Rate for Payer: Cigna All Commercial |
$9,766.97
|
| Rate for Payer: CORVEL All Commercial |
$10,525.24
|
| Rate for Payer: Coventry All Commercial |
$9,959.37
|
| Rate for Payer: Encore All Commercial |
$10,417.72
|
| Rate for Payer: Frontpath All Commercial |
$10,412.07
|
| Rate for Payer: Humana ChoiceCare |
$9,774.89
|
| Rate for Payer: Humana Medicare |
$5,771.91
|
| Rate for Payer: Lucent All Commercial |
$5,771.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,185.72
|
| Rate for Payer: Managed Health Services Medicaid |
$15.02
|
| Rate for Payer: MDWise Medicaid |
$15.02
|
| Rate for Payer: PHCS All Commercial |
$8,488.10
|
| Rate for Payer: PHP All Commercial |
$8,583.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,413.81
|
| Rate for Payer: Sagamore Health Network All Products |
$8,737.08
|
| Rate for Payer: Signature Care EPO |
$9,393.49
|
| Rate for Payer: Signature Care PPO |
$9,959.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9,619.84
|
| Rate for Payer: United Healthcare Commercial |
$8,918.16
|
| Rate for Payer: United Healthcare Medicare |
$3,734.76
|
|
|
PALIPERIDONE PALMITATE 234 MG/1.5 ML IM SYRG
|
Facility
IP
|
$11,317.46
|
|
|
Service Code
|
HCPCS J2426
|
| Hospital Charge Code |
108109
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,488.10 |
| Max. Negotiated Rate |
$10,525.24 |
| Rate for Payer: Aetna Commercial |
$9,778.29
|
| Rate for Payer: Cash Price |
$7,016.83
|
| Rate for Payer: Cigna All Commercial |
$9,766.97
|
| Rate for Payer: CORVEL All Commercial |
$10,525.24
|
| Rate for Payer: Coventry All Commercial |
$9,959.37
|
| Rate for Payer: Encore All Commercial |
$10,417.72
|
| Rate for Payer: Frontpath All Commercial |
$10,412.07
|
| Rate for Payer: Humana ChoiceCare |
$9,774.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10,185.72
|
| Rate for Payer: PHCS All Commercial |
$8,488.10
|
| Rate for Payer: PHP All Commercial |
$8,583.16
|
| Rate for Payer: Sagamore Health Network All Products |
$8,737.08
|
| Rate for Payer: Signature Care EPO |
$9,393.49
|
| Rate for Payer: Signature Care PPO |
$9,959.37
|
| Rate for Payer: United Healthcare Commercial |
$8,918.16
|
|
