|
BUPIVACAINE-DEXTROSE-WATER(PF) 0.75 % (7.5 MG/ML) INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
9316
|
|
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
|
|
|
BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN
|
Facility
|
OP
|
$127.40
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
14983
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.49 |
| Max. Negotiated Rate |
$118.48 |
| Rate for Payer: Aetna Commercial |
$107.53
|
| Rate for Payer: Aetna Medicare |
$40.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$39.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$73.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$79.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$46.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$44.84
|
| Rate for Payer: Cash Price |
$76.44
|
| Rate for Payer: Centivo All Commercial |
$69.31
|
| Rate for Payer: Cigna All Commercial |
$109.95
|
| Rate for Payer: CORVEL All Commercial |
$118.48
|
| Rate for Payer: Coventry All Commercial |
$112.11
|
| Rate for Payer: Encore All Commercial |
$117.27
|
| Rate for Payer: Frontpath All Commercial |
$117.21
|
| Rate for Payer: Humana ChoiceCare |
$110.04
|
| Rate for Payer: Humana Medicare |
$40.77
|
| Rate for Payer: Lucent All Commercial |
$69.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$114.66
|
| Rate for Payer: PHCS All Commercial |
$95.55
|
| Rate for Payer: PHP All Commercial |
$96.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$49.69
|
| Rate for Payer: Sagamore Health Network All Products |
$98.35
|
| Rate for Payer: Signature Care EPO |
$105.74
|
| Rate for Payer: Signature Care PPO |
$112.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$108.29
|
| Rate for Payer: United Healthcare Commercial |
$100.39
|
| Rate for Payer: United Healthcare Medicare |
$40.77
|
|
|
BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN
|
Facility
|
IP
|
$127.40
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
14983
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$95.55 |
| Max. Negotiated Rate |
$118.48 |
| Rate for Payer: Aetna Commercial |
$110.07
|
| Rate for Payer: Cash Price |
$76.44
|
| Rate for Payer: Cigna All Commercial |
$109.95
|
| Rate for Payer: CORVEL All Commercial |
$118.48
|
| Rate for Payer: Coventry All Commercial |
$112.11
|
| Rate for Payer: Encore All Commercial |
$117.27
|
| Rate for Payer: Frontpath All Commercial |
$117.21
|
| Rate for Payer: Humana ChoiceCare |
$110.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$114.66
|
| Rate for Payer: PHCS All Commercial |
$95.55
|
| Rate for Payer: PHP All Commercial |
$96.62
|
| Rate for Payer: Sagamore Health Network All Products |
$98.35
|
| Rate for Payer: Signature Care EPO |
$105.74
|
| Rate for Payer: Signature Care PPO |
$112.11
|
| Rate for Payer: United Healthcare Commercial |
$100.39
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN
|
Facility
|
OP
|
$79.38
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
105633
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.61 |
| Max. Negotiated Rate |
$73.82 |
| Rate for Payer: Aetna Commercial |
$67.00
|
| Rate for Payer: Aetna Commercial |
$42.30
|
| Rate for Payer: Aetna Medicare |
$25.40
|
| Rate for Payer: Aetna Medicare |
$16.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$45.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$28.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$49.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$29.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.94
|
| Rate for Payer: Cash Price |
$47.63
|
| Rate for Payer: Cash Price |
$30.07
|
| Rate for Payer: Centivo All Commercial |
$27.27
|
| Rate for Payer: Centivo All Commercial |
$43.18
|
| Rate for Payer: Cigna All Commercial |
$68.50
|
| Rate for Payer: Cigna All Commercial |
$43.25
|
| Rate for Payer: CORVEL All Commercial |
$46.61
|
| Rate for Payer: CORVEL All Commercial |
$73.82
|
| Rate for Payer: Coventry All Commercial |
$44.11
|
| Rate for Payer: Coventry All Commercial |
$69.85
|
| Rate for Payer: Encore All Commercial |
$73.07
|
| Rate for Payer: Encore All Commercial |
$46.14
|
| Rate for Payer: Frontpath All Commercial |
$46.11
|
| Rate for Payer: Frontpath All Commercial |
$73.03
|
| Rate for Payer: Humana ChoiceCare |
$68.56
|
| Rate for Payer: Humana ChoiceCare |
$43.29
|
| Rate for Payer: Humana Medicare |
$25.40
|
| Rate for Payer: Humana Medicare |
$16.04
|
| Rate for Payer: Lucent All Commercial |
$27.27
|
| Rate for Payer: Lucent All Commercial |
$43.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.11
|
| Rate for Payer: PHCS All Commercial |
$37.59
|
| Rate for Payer: PHCS All Commercial |
$59.53
|
| Rate for Payer: PHP All Commercial |
$38.01
|
| Rate for Payer: PHP All Commercial |
$60.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$30.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.55
|
| Rate for Payer: Sagamore Health Network All Products |
$38.69
|
| Rate for Payer: Sagamore Health Network All Products |
$61.28
|
| Rate for Payer: Signature Care EPO |
$65.89
|
| Rate for Payer: Signature Care EPO |
$41.60
|
| Rate for Payer: Signature Care PPO |
$44.11
|
| Rate for Payer: Signature Care PPO |
$69.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$67.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$42.60
|
| Rate for Payer: United Healthcare Commercial |
$39.49
|
| Rate for Payer: United Healthcare Commercial |
$62.55
|
| Rate for Payer: United Healthcare Medicare |
$16.04
|
| Rate for Payer: United Healthcare Medicare |
$25.40
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN
|
Facility
|
IP
|
$50.12
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
105633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.59 |
| Max. Negotiated Rate |
$46.61 |
| Rate for Payer: Aetna Commercial |
$43.30
|
| Rate for Payer: Aetna Commercial |
$68.58
|
| Rate for Payer: Cash Price |
$30.07
|
| Rate for Payer: Cash Price |
$47.63
|
| Rate for Payer: Cigna All Commercial |
$43.25
|
| Rate for Payer: Cigna All Commercial |
$68.50
|
| Rate for Payer: CORVEL All Commercial |
$46.61
|
| Rate for Payer: CORVEL All Commercial |
$73.82
|
| Rate for Payer: Coventry All Commercial |
$69.85
|
| Rate for Payer: Coventry All Commercial |
$44.11
|
| Rate for Payer: Encore All Commercial |
$73.07
|
| Rate for Payer: Encore All Commercial |
$46.14
|
| Rate for Payer: Frontpath All Commercial |
$46.11
|
| Rate for Payer: Frontpath All Commercial |
$73.03
|
| Rate for Payer: Humana ChoiceCare |
$43.29
|
| Rate for Payer: Humana ChoiceCare |
$68.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.44
|
| Rate for Payer: PHCS All Commercial |
$59.53
|
| Rate for Payer: PHCS All Commercial |
$37.59
|
| Rate for Payer: PHP All Commercial |
$38.01
|
| Rate for Payer: PHP All Commercial |
$60.20
|
| Rate for Payer: Sagamore Health Network All Products |
$61.28
|
| Rate for Payer: Sagamore Health Network All Products |
$38.69
|
| Rate for Payer: Signature Care EPO |
$65.89
|
| Rate for Payer: Signature Care EPO |
$41.60
|
| Rate for Payer: Signature Care PPO |
$44.11
|
| Rate for Payer: Signature Care PPO |
$69.85
|
| Rate for Payer: United Healthcare Commercial |
$39.49
|
| Rate for Payer: United Healthcare Commercial |
$62.55
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN
|
Facility
|
OP
|
$51.38
|
|
|
Service Code
|
NDC 63323046217
|
| Hospital Charge Code |
105634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$47.78 |
| Rate for Payer: Aetna Commercial |
$43.36
|
| Rate for Payer: Aetna Medicare |
$16.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$29.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$32.12
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.09
|
| Rate for Payer: Cash Price |
$30.83
|
| Rate for Payer: Cash Price |
$30.83
|
| Rate for Payer: Centivo All Commercial |
$27.95
|
| Rate for Payer: Cigna All Commercial |
$44.34
|
| Rate for Payer: CORVEL All Commercial |
$47.78
|
| Rate for Payer: Coventry All Commercial |
$45.21
|
| Rate for Payer: Encore All Commercial |
$47.30
|
| Rate for Payer: Frontpath All Commercial |
$47.27
|
| Rate for Payer: Humana ChoiceCare |
$44.38
|
| Rate for Payer: Humana Medicare |
$16.44
|
| Rate for Payer: Lucent All Commercial |
$27.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.24
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$38.53
|
| Rate for Payer: PHP All Commercial |
$38.97
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$20.04
|
| Rate for Payer: Sagamore Health Network All Products |
$39.67
|
| Rate for Payer: Signature Care EPO |
$42.65
|
| Rate for Payer: Signature Care PPO |
$45.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$43.67
|
| Rate for Payer: United Healthcare Commercial |
$40.49
|
| Rate for Payer: United Healthcare Medicare |
$16.44
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN
|
Facility
|
IP
|
$51.38
|
|
|
Service Code
|
NDC 63323046217
|
| Hospital Charge Code |
105634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.53 |
| Max. Negotiated Rate |
$47.78 |
| Rate for Payer: Aetna Commercial |
$44.39
|
| Rate for Payer: Cash Price |
$30.83
|
| Rate for Payer: Cigna All Commercial |
$44.34
|
| Rate for Payer: CORVEL All Commercial |
$47.78
|
| Rate for Payer: Coventry All Commercial |
$45.21
|
| Rate for Payer: Encore All Commercial |
$47.30
|
| Rate for Payer: Frontpath All Commercial |
$47.27
|
| Rate for Payer: Humana ChoiceCare |
$44.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.24
|
| Rate for Payer: PHCS All Commercial |
$38.53
|
| Rate for Payer: PHP All Commercial |
$38.97
|
| Rate for Payer: Sagamore Health Network All Products |
$39.67
|
| Rate for Payer: Signature Care EPO |
$42.65
|
| Rate for Payer: Signature Care PPO |
$45.21
|
| Rate for Payer: United Healthcare Commercial |
$40.49
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN
|
Facility
|
OP
|
$34.86
|
|
|
Service Code
|
NDC 00409174929
|
| Hospital Charge Code |
105634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$32.42 |
| Rate for Payer: Aetna Commercial |
$29.42
|
| Rate for Payer: Aetna Medicare |
$11.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$20.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.79
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.27
|
| Rate for Payer: Cash Price |
$20.92
|
| Rate for Payer: Cash Price |
$20.92
|
| Rate for Payer: Centivo All Commercial |
$18.96
|
| Rate for Payer: Cigna All Commercial |
$30.08
|
| Rate for Payer: CORVEL All Commercial |
$32.42
|
| Rate for Payer: Coventry All Commercial |
$30.68
|
| Rate for Payer: Encore All Commercial |
$32.09
|
| Rate for Payer: Frontpath All Commercial |
$32.07
|
| Rate for Payer: Humana ChoiceCare |
$30.11
|
| Rate for Payer: Humana Medicare |
$11.16
|
| Rate for Payer: Lucent All Commercial |
$18.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.37
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$26.14
|
| Rate for Payer: PHP All Commercial |
$26.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.60
|
| Rate for Payer: Sagamore Health Network All Products |
$26.91
|
| Rate for Payer: Signature Care EPO |
$28.93
|
| Rate for Payer: Signature Care PPO |
$30.68
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.63
|
| Rate for Payer: United Healthcare Commercial |
$27.47
|
| Rate for Payer: United Healthcare Medicare |
$11.16
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN
|
Facility
|
IP
|
$34.86
|
|
|
Service Code
|
NDC 00409174929
|
| Hospital Charge Code |
105634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.14 |
| Max. Negotiated Rate |
$32.42 |
| Rate for Payer: Aetna Commercial |
$30.12
|
| Rate for Payer: Cash Price |
$20.92
|
| Rate for Payer: Cigna All Commercial |
$30.08
|
| Rate for Payer: CORVEL All Commercial |
$32.42
|
| Rate for Payer: Coventry All Commercial |
$30.68
|
| Rate for Payer: Encore All Commercial |
$32.09
|
| Rate for Payer: Frontpath All Commercial |
$32.07
|
| Rate for Payer: Humana ChoiceCare |
$30.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.37
|
| Rate for Payer: PHCS All Commercial |
$26.14
|
| Rate for Payer: PHP All Commercial |
$26.44
|
| Rate for Payer: Sagamore Health Network All Products |
$26.91
|
| Rate for Payer: Signature Care EPO |
$28.93
|
| Rate for Payer: Signature Care PPO |
$30.68
|
| Rate for Payer: United Healthcare Commercial |
$27.47
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.75 %-1:200,000 INJ SOLN
|
Facility
|
OP
|
$95.97
|
|
|
Service Code
|
NDC 63323046037
|
| Hospital Charge Code |
114890
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.75 |
| Max. Negotiated Rate |
$89.25 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Medicare |
$30.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$29.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$55.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$59.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$35.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$33.78
|
| Rate for Payer: Cash Price |
$57.58
|
| Rate for Payer: Centivo All Commercial |
$52.21
|
| Rate for Payer: Cigna All Commercial |
$82.82
|
| Rate for Payer: CORVEL All Commercial |
$89.25
|
| Rate for Payer: Coventry All Commercial |
$84.45
|
| Rate for Payer: Encore All Commercial |
$88.34
|
| Rate for Payer: Frontpath All Commercial |
$88.29
|
| Rate for Payer: Humana ChoiceCare |
$82.89
|
| Rate for Payer: Humana Medicare |
$30.71
|
| Rate for Payer: Lucent All Commercial |
$52.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$86.37
|
| Rate for Payer: PHCS All Commercial |
$71.98
|
| Rate for Payer: PHP All Commercial |
$72.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$37.43
|
| Rate for Payer: Sagamore Health Network All Products |
$74.09
|
| Rate for Payer: Signature Care EPO |
$79.66
|
| Rate for Payer: Signature Care PPO |
$84.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$81.57
|
| Rate for Payer: United Healthcare Commercial |
$75.62
|
| Rate for Payer: United Healthcare Medicare |
$30.71
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.75 %-1:200,000 INJ SOLN
|
Facility
|
IP
|
$95.97
|
|
|
Service Code
|
NDC 63323046037
|
| Hospital Charge Code |
114890
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$71.98 |
| Max. Negotiated Rate |
$89.25 |
| Rate for Payer: Aetna Commercial |
$82.92
|
| Rate for Payer: Cash Price |
$57.58
|
| Rate for Payer: Cigna All Commercial |
$82.82
|
| Rate for Payer: CORVEL All Commercial |
$89.25
|
| Rate for Payer: Coventry All Commercial |
$84.45
|
| Rate for Payer: Encore All Commercial |
$88.34
|
| Rate for Payer: Frontpath All Commercial |
$88.29
|
| Rate for Payer: Humana ChoiceCare |
$82.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$86.37
|
| Rate for Payer: PHCS All Commercial |
$71.98
|
| Rate for Payer: PHP All Commercial |
$72.78
|
| Rate for Payer: Sagamore Health Network All Products |
$74.09
|
| Rate for Payer: Signature Care EPO |
$79.66
|
| Rate for Payer: Signature Care PPO |
$84.45
|
| Rate for Payer: United Healthcare Commercial |
$75.62
|
|
|
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
1223
|
|
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
|
|
|
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
1223
|
|
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
|
|
|
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN
|
Facility
|
OP
|
$22.12
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
1222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.86 |
| Max. Negotiated Rate |
$20.57 |
| Rate for Payer: Aetna Commercial |
$18.67
|
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Aetna Medicare |
$7.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$12.70
|
| 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: Anthem Blue Cross of IN Traditional |
$13.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.79
|
| Rate for Payer: Cash Price |
$13.27
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$12.03
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$19.09
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$20.57
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Coventry All Commercial |
$19.47
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Encore All Commercial |
$20.36
|
| Rate for Payer: Frontpath All Commercial |
$20.35
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$19.11
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$7.08
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lucent All Commercial |
$12.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$16.59
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$16.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.63
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Sagamore Health Network All Products |
$17.08
|
| Rate for Payer: Signature Care EPO |
$18.36
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$19.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$17.43
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
| Rate for Payer: United Healthcare Medicare |
$7.08
|
|
|
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN
|
Facility
|
IP
|
$22.12
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
1222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.59 |
| Max. Negotiated Rate |
$20.57 |
| Rate for Payer: Aetna Commercial |
$19.11
|
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$13.27
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$19.09
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$20.57
|
| Rate for Payer: Coventry All Commercial |
$19.47
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$20.36
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Frontpath All Commercial |
$20.35
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana ChoiceCare |
$19.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.91
|
| Rate for Payer: PHCS All Commercial |
$16.59
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$16.78
|
| Rate for Payer: Sagamore Health Network All Products |
$17.08
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$18.36
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$19.47
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$17.43
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
105640
|
|
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
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
105640
|
|
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
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
1224
|
|
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
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
1224
|
|
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
|
|
|
BUPRENORPHINE-NALOXONE 2-0.5 MG SL FILM
|
Facility
|
OP
|
$32.88
|
|
|
Service Code
|
NDC 12496120203
|
| Hospital Charge Code |
106176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$30.58 |
| Rate for Payer: Aetna Commercial |
$27.75
|
| Rate for Payer: Aetna Medicare |
$10.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$18.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.57
|
| Rate for Payer: Cash Price |
$19.73
|
| Rate for Payer: Centivo All Commercial |
$17.89
|
| Rate for Payer: Cigna All Commercial |
$28.37
|
| Rate for Payer: CORVEL All Commercial |
$30.58
|
| Rate for Payer: Coventry All Commercial |
$28.93
|
| Rate for Payer: Encore All Commercial |
$30.27
|
| Rate for Payer: Frontpath All Commercial |
$30.25
|
| Rate for Payer: Humana ChoiceCare |
$28.40
|
| Rate for Payer: Humana Medicare |
$10.52
|
| Rate for Payer: Lucent All Commercial |
$17.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.59
|
| Rate for Payer: PHCS All Commercial |
$24.66
|
| Rate for Payer: PHP All Commercial |
$24.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.82
|
| Rate for Payer: Sagamore Health Network All Products |
$25.38
|
| Rate for Payer: Signature Care EPO |
$27.29
|
| Rate for Payer: Signature Care PPO |
$28.93
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27.95
|
| Rate for Payer: United Healthcare Commercial |
$25.91
|
| Rate for Payer: United Healthcare Medicare |
$10.52
|
|
|
BUPRENORPHINE-NALOXONE 2-0.5 MG SL FILM
|
Facility
|
OP
|
$32.88
|
|
|
Service Code
|
NDC 12496120201
|
| Hospital Charge Code |
106176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$30.58 |
| Rate for Payer: Aetna Commercial |
$27.75
|
| Rate for Payer: Aetna Medicare |
$10.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$18.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.57
|
| Rate for Payer: Cash Price |
$19.73
|
| Rate for Payer: Centivo All Commercial |
$17.89
|
| Rate for Payer: Cigna All Commercial |
$28.37
|
| Rate for Payer: CORVEL All Commercial |
$30.58
|
| Rate for Payer: Coventry All Commercial |
$28.93
|
| Rate for Payer: Encore All Commercial |
$30.27
|
| Rate for Payer: Frontpath All Commercial |
$30.25
|
| Rate for Payer: Humana ChoiceCare |
$28.40
|
| Rate for Payer: Humana Medicare |
$10.52
|
| Rate for Payer: Lucent All Commercial |
$17.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.59
|
| Rate for Payer: PHCS All Commercial |
$24.66
|
| Rate for Payer: PHP All Commercial |
$24.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.82
|
| Rate for Payer: Sagamore Health Network All Products |
$25.38
|
| Rate for Payer: Signature Care EPO |
$27.29
|
| Rate for Payer: Signature Care PPO |
$28.93
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27.95
|
| Rate for Payer: United Healthcare Commercial |
$25.91
|
| Rate for Payer: United Healthcare Medicare |
$10.52
|
|
|
BUPRENORPHINE-NALOXONE 2-0.5 MG SL FILM
|
Facility
|
IP
|
$32.88
|
|
|
Service Code
|
NDC 12496120203
|
| Hospital Charge Code |
106176
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.66 |
| Max. Negotiated Rate |
$30.58 |
| Rate for Payer: Aetna Commercial |
$28.41
|
| Rate for Payer: Cash Price |
$19.73
|
| Rate for Payer: Cigna All Commercial |
$28.37
|
| Rate for Payer: CORVEL All Commercial |
$30.58
|
| Rate for Payer: Coventry All Commercial |
$28.93
|
| Rate for Payer: Encore All Commercial |
$30.27
|
| Rate for Payer: Frontpath All Commercial |
$30.25
|
| Rate for Payer: Humana ChoiceCare |
$28.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.59
|
| Rate for Payer: PHCS All Commercial |
$24.66
|
| Rate for Payer: PHP All Commercial |
$24.94
|
| Rate for Payer: Sagamore Health Network All Products |
$25.38
|
| Rate for Payer: Signature Care EPO |
$27.29
|
| Rate for Payer: Signature Care PPO |
$28.93
|
| Rate for Payer: United Healthcare Commercial |
$25.91
|
|
|
BUPRENORPHINE-NALOXONE 2-0.5 MG SL FILM
|
Facility
|
IP
|
$32.88
|
|
|
Service Code
|
NDC 12496120201
|
| Hospital Charge Code |
106176
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.66 |
| Max. Negotiated Rate |
$30.58 |
| Rate for Payer: Aetna Commercial |
$28.41
|
| Rate for Payer: Cash Price |
$19.73
|
| Rate for Payer: Cigna All Commercial |
$28.37
|
| Rate for Payer: CORVEL All Commercial |
$30.58
|
| Rate for Payer: Coventry All Commercial |
$28.93
|
| Rate for Payer: Encore All Commercial |
$30.27
|
| Rate for Payer: Frontpath All Commercial |
$30.25
|
| Rate for Payer: Humana ChoiceCare |
$28.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.59
|
| Rate for Payer: PHCS All Commercial |
$24.66
|
| Rate for Payer: PHP All Commercial |
$24.94
|
| Rate for Payer: Sagamore Health Network All Products |
$25.38
|
| Rate for Payer: Signature Care EPO |
$27.29
|
| Rate for Payer: Signature Care PPO |
$28.93
|
| Rate for Payer: United Healthcare Commercial |
$25.91
|
|
|
BUPRENORPHINE-NALOXONE 8-2 MG SL FILM
|
Facility
|
OP
|
$58.93
|
|
|
Service Code
|
HCPCS J0572
|
| Hospital Charge Code |
106177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.27 |
| Max. Negotiated Rate |
$54.81 |
| Rate for Payer: Aetna Commercial |
$49.74
|
| Rate for Payer: Aetna Medicare |
$18.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$33.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$36.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.74
|
| Rate for Payer: Cash Price |
$35.36
|
| Rate for Payer: Centivo All Commercial |
$32.06
|
| Rate for Payer: Cigna All Commercial |
$50.86
|
| Rate for Payer: CORVEL All Commercial |
$54.81
|
| Rate for Payer: Coventry All Commercial |
$51.86
|
| Rate for Payer: Encore All Commercial |
$54.25
|
| Rate for Payer: Frontpath All Commercial |
$54.22
|
| Rate for Payer: Humana ChoiceCare |
$50.90
|
| Rate for Payer: Humana Medicare |
$18.86
|
| Rate for Payer: Lucent All Commercial |
$32.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.04
|
| Rate for Payer: PHCS All Commercial |
$44.20
|
| Rate for Payer: PHP All Commercial |
$44.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.98
|
| Rate for Payer: Sagamore Health Network All Products |
$45.50
|
| Rate for Payer: Signature Care EPO |
$48.91
|
| Rate for Payer: Signature Care PPO |
$51.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$50.09
|
| Rate for Payer: United Healthcare Commercial |
$46.44
|
| Rate for Payer: United Healthcare Medicare |
$18.86
|
|
|
BUPRENORPHINE-NALOXONE 8-2 MG SL FILM
|
Facility
|
IP
|
$58.93
|
|
|
Service Code
|
HCPCS J0572
|
| Hospital Charge Code |
106177
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$54.81 |
| Rate for Payer: Aetna Commercial |
$50.92
|
| Rate for Payer: Cash Price |
$35.36
|
| Rate for Payer: Cigna All Commercial |
$50.86
|
| Rate for Payer: CORVEL All Commercial |
$54.81
|
| Rate for Payer: Coventry All Commercial |
$51.86
|
| Rate for Payer: Encore All Commercial |
$54.25
|
| Rate for Payer: Frontpath All Commercial |
$54.22
|
| Rate for Payer: Humana ChoiceCare |
$50.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.04
|
| Rate for Payer: PHCS All Commercial |
$44.20
|
| Rate for Payer: PHP All Commercial |
$44.69
|
| Rate for Payer: Sagamore Health Network All Products |
$45.50
|
| Rate for Payer: Signature Care EPO |
$48.91
|
| Rate for Payer: Signature Care PPO |
$51.86
|
| Rate for Payer: United Healthcare Commercial |
$46.44
|
|
