|
KIT PREP OF TC-99M-TETROFOSMIN 1.38 MG IV SOLR STRESS DOSE
|
Facility
|
OP
|
$330.30
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
140171719
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$102.39 |
| Max. Negotiated Rate |
$307.18 |
| Rate for Payer: Aetna Commercial |
$278.77
|
| Rate for Payer: Aetna Medicare |
$105.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$297.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$102.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$189.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$206.47
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$297.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$121.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$116.27
|
| Rate for Payer: Cash Price |
$198.18
|
| Rate for Payer: Centivo All Commercial |
$179.68
|
| Rate for Payer: Cigna All Commercial |
$285.05
|
| Rate for Payer: CORVEL All Commercial |
$307.18
|
| Rate for Payer: Coventry All Commercial |
$290.66
|
| Rate for Payer: Encore All Commercial |
$304.04
|
| Rate for Payer: Frontpath All Commercial |
$303.88
|
| Rate for Payer: Humana ChoiceCare |
$285.28
|
| Rate for Payer: Humana Medicare |
$105.70
|
| Rate for Payer: Lucent All Commercial |
$179.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$297.27
|
| Rate for Payer: Managed Health Services Medicaid |
$297.27
|
| Rate for Payer: MDWise Medicaid |
$297.27
|
| Rate for Payer: PHCS All Commercial |
$247.72
|
| Rate for Payer: PHP All Commercial |
$250.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$128.82
|
| Rate for Payer: Sagamore Health Network All Products |
$254.99
|
| Rate for Payer: Signature Care EPO |
$274.15
|
| Rate for Payer: Signature Care PPO |
$290.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$280.75
|
| Rate for Payer: United Healthcare Commercial |
$260.28
|
| Rate for Payer: United Healthcare Medicare |
$105.70
|
|
|
KIT PREP TC-99M-EXAMETAZIME 0.5 MG IV KIT
|
Facility
|
OP
|
$10,489.05
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
153749
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$3,251.60 |
| Max. Negotiated Rate |
$9,754.81 |
| Rate for Payer: Aetna Commercial |
$8,852.75
|
| Rate for Payer: Aetna Medicare |
$3,356.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,251.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6,023.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6,556.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,859.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,692.14
|
| Rate for Payer: Cash Price |
$6,293.43
|
| Rate for Payer: Centivo All Commercial |
$5,706.04
|
| Rate for Payer: Cigna All Commercial |
$9,052.05
|
| Rate for Payer: CORVEL All Commercial |
$9,754.81
|
| Rate for Payer: Coventry All Commercial |
$9,230.36
|
| Rate for Payer: Encore All Commercial |
$9,655.17
|
| Rate for Payer: Frontpath All Commercial |
$9,649.92
|
| Rate for Payer: Humana ChoiceCare |
$9,059.39
|
| Rate for Payer: Humana Medicare |
$3,356.49
|
| Rate for Payer: Lucent All Commercial |
$5,706.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,440.14
|
| Rate for Payer: PHCS All Commercial |
$7,866.78
|
| Rate for Payer: PHP All Commercial |
$7,954.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,090.73
|
| Rate for Payer: Sagamore Health Network All Products |
$8,097.54
|
| Rate for Payer: Signature Care EPO |
$8,705.91
|
| Rate for Payer: Signature Care PPO |
$9,230.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,915.69
|
| Rate for Payer: United Healthcare Commercial |
$8,265.37
|
| Rate for Payer: United Healthcare Medicare |
$3,356.49
|
|
|
KIT PREP TC-99M-EXAMETAZIME 0.5 MG IV KIT
|
Facility
|
IP
|
$10,489.05
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
153749
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7,866.78 |
| Max. Negotiated Rate |
$9,754.81 |
| Rate for Payer: Aetna Commercial |
$9,062.53
|
| Rate for Payer: Cash Price |
$6,293.43
|
| Rate for Payer: Cigna All Commercial |
$9,052.05
|
| Rate for Payer: CORVEL All Commercial |
$9,754.81
|
| Rate for Payer: Coventry All Commercial |
$9,230.36
|
| Rate for Payer: Encore All Commercial |
$9,655.17
|
| Rate for Payer: Frontpath All Commercial |
$9,649.92
|
| Rate for Payer: Humana ChoiceCare |
$9,059.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,440.14
|
| Rate for Payer: PHCS All Commercial |
$7,866.78
|
| Rate for Payer: PHP All Commercial |
$7,954.89
|
| Rate for Payer: Sagamore Health Network All Products |
$8,097.54
|
| Rate for Payer: Signature Care EPO |
$8,705.91
|
| Rate for Payer: Signature Care PPO |
$9,230.36
|
| Rate for Payer: United Healthcare Commercial |
$8,265.37
|
|
|
KIT PREP TC-99M-MEDRONATE SOD 20 MG IV SOLR
|
Facility
|
OP
|
$356.58
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
121124
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$110.54 |
| Max. Negotiated Rate |
$331.62 |
| Rate for Payer: Aetna Commercial |
$300.95
|
| Rate for Payer: Aetna Medicare |
$114.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$110.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$204.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$222.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$131.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$125.52
|
| Rate for Payer: Cash Price |
$213.95
|
| Rate for Payer: Centivo All Commercial |
$193.98
|
| Rate for Payer: Cigna All Commercial |
$307.73
|
| Rate for Payer: CORVEL All Commercial |
$331.62
|
| Rate for Payer: Coventry All Commercial |
$313.79
|
| Rate for Payer: Encore All Commercial |
$328.23
|
| Rate for Payer: Frontpath All Commercial |
$328.05
|
| Rate for Payer: Humana ChoiceCare |
$307.98
|
| Rate for Payer: Humana Medicare |
$114.11
|
| Rate for Payer: Lucent All Commercial |
$193.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$320.92
|
| Rate for Payer: PHCS All Commercial |
$267.44
|
| Rate for Payer: PHP All Commercial |
$270.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$139.07
|
| Rate for Payer: Sagamore Health Network All Products |
$275.28
|
| Rate for Payer: Signature Care EPO |
$295.96
|
| Rate for Payer: Signature Care PPO |
$313.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$303.09
|
| Rate for Payer: United Healthcare Commercial |
$280.99
|
| Rate for Payer: United Healthcare Medicare |
$114.11
|
|
|
KIT PREP TC-99M-MEDRONATE SOD 20 MG IV SOLR
|
Facility
|
IP
|
$356.58
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
121124
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$267.44 |
| Max. Negotiated Rate |
$331.62 |
| Rate for Payer: Aetna Commercial |
$308.09
|
| Rate for Payer: Cash Price |
$213.95
|
| Rate for Payer: Cigna All Commercial |
$307.73
|
| Rate for Payer: CORVEL All Commercial |
$331.62
|
| Rate for Payer: Coventry All Commercial |
$313.79
|
| Rate for Payer: Encore All Commercial |
$328.23
|
| Rate for Payer: Frontpath All Commercial |
$328.05
|
| Rate for Payer: Humana ChoiceCare |
$307.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$320.92
|
| Rate for Payer: PHCS All Commercial |
$267.44
|
| Rate for Payer: PHP All Commercial |
$270.43
|
| Rate for Payer: Sagamore Health Network All Products |
$275.28
|
| Rate for Payer: Signature Care EPO |
$295.96
|
| Rate for Payer: Signature Care PPO |
$313.79
|
| Rate for Payer: United Healthcare Commercial |
$280.99
|
|
|
KIT PREP TC 99M-PENTETIC ACID 20 MG IV SOLR
|
Facility
|
OP
|
$992.90
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
152912
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$307.80 |
| Max. Negotiated Rate |
$923.40 |
| Rate for Payer: Aetna Commercial |
$838.01
|
| Rate for Payer: Aetna Medicare |
$317.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$307.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$570.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$620.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$365.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$349.50
|
| Rate for Payer: Cash Price |
$595.74
|
| Rate for Payer: Centivo All Commercial |
$540.14
|
| Rate for Payer: Cigna All Commercial |
$856.87
|
| Rate for Payer: CORVEL All Commercial |
$923.40
|
| Rate for Payer: Coventry All Commercial |
$873.75
|
| Rate for Payer: Encore All Commercial |
$913.96
|
| Rate for Payer: Frontpath All Commercial |
$913.47
|
| Rate for Payer: Humana ChoiceCare |
$857.57
|
| Rate for Payer: Humana Medicare |
$317.73
|
| Rate for Payer: Lucent All Commercial |
$540.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$893.61
|
| Rate for Payer: PHCS All Commercial |
$744.67
|
| Rate for Payer: PHP All Commercial |
$753.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$387.23
|
| Rate for Payer: Sagamore Health Network All Products |
$766.52
|
| Rate for Payer: Signature Care EPO |
$824.11
|
| Rate for Payer: Signature Care PPO |
$873.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$843.97
|
| Rate for Payer: United Healthcare Commercial |
$782.41
|
| Rate for Payer: United Healthcare Medicare |
$317.73
|
|
|
KIT PREP TC 99M-PENTETIC ACID 20 MG IV SOLR
|
Facility
|
IP
|
$992.90
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
152912
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$744.67 |
| Max. Negotiated Rate |
$923.40 |
| Rate for Payer: Aetna Commercial |
$857.87
|
| Rate for Payer: Cash Price |
$595.74
|
| Rate for Payer: Cigna All Commercial |
$856.87
|
| Rate for Payer: CORVEL All Commercial |
$923.40
|
| Rate for Payer: Coventry All Commercial |
$873.75
|
| Rate for Payer: Encore All Commercial |
$913.96
|
| Rate for Payer: Frontpath All Commercial |
$913.47
|
| Rate for Payer: Humana ChoiceCare |
$857.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$893.61
|
| Rate for Payer: PHCS All Commercial |
$744.67
|
| Rate for Payer: PHP All Commercial |
$753.02
|
| Rate for Payer: Sagamore Health Network All Products |
$766.52
|
| Rate for Payer: Signature Care EPO |
$824.11
|
| Rate for Payer: Signature Care PPO |
$873.75
|
| Rate for Payer: United Healthcare Commercial |
$782.41
|
|
|
LABETALOL 200 MG ORAL TAB
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 60687045001
|
| Hospital Charge Code |
10374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$3.69 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna All Commercial |
$3.43
|
| Rate for Payer: CORVEL All Commercial |
$3.69
|
| Rate for Payer: Coventry All Commercial |
$3.49
|
| Rate for Payer: Encore All Commercial |
$3.65
|
| Rate for Payer: Frontpath All Commercial |
$3.65
|
| Rate for Payer: Humana ChoiceCare |
$3.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.57
|
| Rate for Payer: PHCS All Commercial |
$2.98
|
| Rate for Payer: PHP All Commercial |
$3.01
|
| Rate for Payer: Sagamore Health Network All Products |
$3.06
|
| Rate for Payer: Signature Care EPO |
$3.29
|
| Rate for Payer: Signature Care PPO |
$3.49
|
| Rate for Payer: United Healthcare Commercial |
$3.13
|
|
|
LABETALOL 200 MG ORAL TAB
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 60687045001
|
| Hospital Charge Code |
10374
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$3.69 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Aetna Medicare |
$1.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.40
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Centivo All Commercial |
$2.16
|
| Rate for Payer: Cigna All Commercial |
$3.43
|
| Rate for Payer: CORVEL All Commercial |
$3.69
|
| Rate for Payer: Coventry All Commercial |
$3.49
|
| Rate for Payer: Encore All Commercial |
$3.65
|
| Rate for Payer: Frontpath All Commercial |
$3.65
|
| Rate for Payer: Humana ChoiceCare |
$3.43
|
| Rate for Payer: Humana Medicare |
$1.27
|
| Rate for Payer: Lucent All Commercial |
$2.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.57
|
| Rate for Payer: PHCS All Commercial |
$2.98
|
| Rate for Payer: PHP All Commercial |
$3.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.55
|
| Rate for Payer: Sagamore Health Network All Products |
$3.06
|
| Rate for Payer: Signature Care EPO |
$3.29
|
| Rate for Payer: Signature Care PPO |
$3.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.37
|
| Rate for Payer: United Healthcare Commercial |
$3.13
|
| Rate for Payer: United Healthcare Medicare |
$1.27
|
|
|
LABETALOL 200 MG ORAL TAB
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 60687045011
|
| Hospital Charge Code |
10374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$3.69 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna All Commercial |
$3.43
|
| Rate for Payer: CORVEL All Commercial |
$3.69
|
| Rate for Payer: Coventry All Commercial |
$3.49
|
| Rate for Payer: Encore All Commercial |
$3.65
|
| Rate for Payer: Frontpath All Commercial |
$3.65
|
| Rate for Payer: Humana ChoiceCare |
$3.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.57
|
| Rate for Payer: PHCS All Commercial |
$2.98
|
| Rate for Payer: PHP All Commercial |
$3.01
|
| Rate for Payer: Sagamore Health Network All Products |
$3.06
|
| Rate for Payer: Signature Care EPO |
$3.29
|
| Rate for Payer: Signature Care PPO |
$3.49
|
| Rate for Payer: United Healthcare Commercial |
$3.13
|
|
|
LABETALOL 200 MG ORAL TAB
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 60687045011
|
| Hospital Charge Code |
10374
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$3.69 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Aetna Medicare |
$1.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.40
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Centivo All Commercial |
$2.16
|
| Rate for Payer: Cigna All Commercial |
$3.43
|
| Rate for Payer: CORVEL All Commercial |
$3.69
|
| Rate for Payer: Coventry All Commercial |
$3.49
|
| Rate for Payer: Encore All Commercial |
$3.65
|
| Rate for Payer: Frontpath All Commercial |
$3.65
|
| Rate for Payer: Humana ChoiceCare |
$3.43
|
| Rate for Payer: Humana Medicare |
$1.27
|
| Rate for Payer: Lucent All Commercial |
$2.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.57
|
| Rate for Payer: PHCS All Commercial |
$2.98
|
| Rate for Payer: PHP All Commercial |
$3.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.55
|
| Rate for Payer: Sagamore Health Network All Products |
$3.06
|
| Rate for Payer: Signature Care EPO |
$3.29
|
| Rate for Payer: Signature Care PPO |
$3.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.37
|
| Rate for Payer: United Healthcare Commercial |
$3.13
|
| Rate for Payer: United Healthcare Medicare |
$1.27
|
|
|
LABETALOL 20 MG/4 ML (5 MG/ML) IV SYRG
|
Facility
|
IP
|
$54.24
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
153505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.68 |
| Max. Negotiated Rate |
$50.44 |
| Rate for Payer: Aetna Commercial |
$46.86
|
| Rate for Payer: Cash Price |
$32.54
|
| Rate for Payer: Cigna All Commercial |
$46.81
|
| Rate for Payer: CORVEL All Commercial |
$50.44
|
| Rate for Payer: Coventry All Commercial |
$47.73
|
| Rate for Payer: Encore All Commercial |
$49.92
|
| Rate for Payer: Frontpath All Commercial |
$49.90
|
| Rate for Payer: Humana ChoiceCare |
$46.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.81
|
| Rate for Payer: PHCS All Commercial |
$40.68
|
| Rate for Payer: PHP All Commercial |
$41.13
|
| Rate for Payer: Sagamore Health Network All Products |
$41.87
|
| Rate for Payer: Signature Care EPO |
$45.02
|
| Rate for Payer: Signature Care PPO |
$47.73
|
| Rate for Payer: United Healthcare Commercial |
$42.74
|
|
|
LABETALOL 20 MG/4 ML (5 MG/ML) IV SYRG
|
Facility
|
OP
|
$54.24
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
153505
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.81 |
| Max. Negotiated Rate |
$50.44 |
| Rate for Payer: Aetna Commercial |
$45.78
|
| Rate for Payer: Aetna Medicare |
$17.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$31.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$33.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$19.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.09
|
| Rate for Payer: Cash Price |
$32.54
|
| Rate for Payer: Centivo All Commercial |
$29.50
|
| Rate for Payer: Cigna All Commercial |
$46.81
|
| Rate for Payer: CORVEL All Commercial |
$50.44
|
| Rate for Payer: Coventry All Commercial |
$47.73
|
| Rate for Payer: Encore All Commercial |
$49.92
|
| Rate for Payer: Frontpath All Commercial |
$49.90
|
| Rate for Payer: Humana ChoiceCare |
$46.84
|
| Rate for Payer: Humana Medicare |
$17.36
|
| Rate for Payer: Lucent All Commercial |
$29.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.81
|
| Rate for Payer: PHCS All Commercial |
$40.68
|
| Rate for Payer: PHP All Commercial |
$41.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$21.15
|
| Rate for Payer: Sagamore Health Network All Products |
$41.87
|
| Rate for Payer: Signature Care EPO |
$45.02
|
| Rate for Payer: Signature Care PPO |
$47.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$46.10
|
| Rate for Payer: United Healthcare Commercial |
$42.74
|
| Rate for Payer: United Healthcare Medicare |
$17.36
|
|
|
LABETALOL 5 MG/ML IV SOLN
|
Facility
|
IP
|
$48.16
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
10372
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.12 |
| Max. Negotiated Rate |
$44.79 |
| Rate for Payer: Aetna Commercial |
$41.61
|
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$28.90
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$41.56
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$44.79
|
| Rate for Payer: Coventry All Commercial |
$42.38
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$44.33
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Frontpath All Commercial |
$44.31
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana ChoiceCare |
$41.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.34
|
| Rate for Payer: PHCS All Commercial |
$36.12
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$36.52
|
| Rate for Payer: Sagamore Health Network All Products |
$37.18
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$39.97
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$42.38
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$37.95
|
|
|
LABETALOL 5 MG/ML IV SOLN
|
Facility
|
OP
|
$48.16
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
10372
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.93 |
| Max. Negotiated Rate |
$44.79 |
| Rate for Payer: Aetna Commercial |
$40.65
|
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Aetna Medicare |
$15.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$27.66
|
| 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 |
$30.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.95
|
| Rate for Payer: Cash Price |
$28.90
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$26.20
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$41.56
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$44.79
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Coventry All Commercial |
$42.38
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Encore All Commercial |
$44.33
|
| Rate for Payer: Frontpath All Commercial |
$44.31
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$41.60
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$15.41
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lucent All Commercial |
$26.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$36.12
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$36.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.78
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Sagamore Health Network All Products |
$37.18
|
| Rate for Payer: Signature Care EPO |
$39.97
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$42.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$37.95
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
| Rate for Payer: United Healthcare Medicare |
$15.41
|
|
|
LACOSAMIDE 50 MG ORAL TAB
|
Facility
|
IP
|
$5.05
|
|
|
Service Code
|
NDC 00904724468
|
| Hospital Charge Code |
96968
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$4.36
|
| Rate for Payer: Cash Price |
$3.03
|
| Rate for Payer: Cigna All Commercial |
$4.36
|
| Rate for Payer: CORVEL All Commercial |
$4.69
|
| Rate for Payer: Coventry All Commercial |
$4.44
|
| Rate for Payer: Encore All Commercial |
$4.65
|
| Rate for Payer: Frontpath All Commercial |
$4.64
|
| Rate for Payer: Humana ChoiceCare |
$4.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.54
|
| Rate for Payer: PHCS All Commercial |
$3.79
|
| Rate for Payer: PHP All Commercial |
$3.83
|
| Rate for Payer: Sagamore Health Network All Products |
$3.90
|
| Rate for Payer: Signature Care EPO |
$4.19
|
| Rate for Payer: Signature Care PPO |
$4.44
|
| Rate for Payer: United Healthcare Commercial |
$3.98
|
|
|
LACOSAMIDE 50 MG ORAL TAB
|
Facility
|
OP
|
$5.05
|
|
|
Service Code
|
NDC 00904724468
|
| Hospital Charge Code |
96968
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$4.26
|
| Rate for Payer: Aetna Medicare |
$1.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.78
|
| Rate for Payer: Cash Price |
$3.03
|
| Rate for Payer: Centivo All Commercial |
$2.75
|
| Rate for Payer: Cigna All Commercial |
$4.36
|
| Rate for Payer: CORVEL All Commercial |
$4.69
|
| Rate for Payer: Coventry All Commercial |
$4.44
|
| Rate for Payer: Encore All Commercial |
$4.65
|
| Rate for Payer: Frontpath All Commercial |
$4.64
|
| Rate for Payer: Humana ChoiceCare |
$4.36
|
| Rate for Payer: Humana Medicare |
$1.62
|
| Rate for Payer: Lucent All Commercial |
$2.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.54
|
| Rate for Payer: PHCS All Commercial |
$3.79
|
| Rate for Payer: PHP All Commercial |
$3.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.97
|
| Rate for Payer: Sagamore Health Network All Products |
$3.90
|
| Rate for Payer: Signature Care EPO |
$4.19
|
| Rate for Payer: Signature Care PPO |
$4.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.29
|
| Rate for Payer: United Healthcare Commercial |
$3.98
|
| Rate for Payer: United Healthcare Medicare |
$1.62
|
|
|
LACTATED RINGERS IRRIGATION SOLP
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00338011704
|
| Hospital Charge Code |
1404318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$30.24
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
|
|
LACTATED RINGERS IRRIGATION SOLP
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00338011704
|
| Hospital Charge Code |
1404318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$29.54
|
| Rate for Payer: Aetna Medicare |
$11.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$20.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.32
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Centivo All Commercial |
$19.04
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Humana Medicare |
$11.20
|
| Rate for Payer: Lucent All Commercial |
$19.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.75
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
| Rate for Payer: United Healthcare Medicare |
$11.20
|
|
|
LACTATED RINGERS IV SOLP
|
Facility
|
OP
|
$31.50
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
4318
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna Commercial |
$26.59
|
| Rate for Payer: Aetna Commercial |
$29.54
|
| Rate for Payer: Aetna Commercial |
$32.49
|
| Rate for Payer: Aetna Medicare |
$11.20
|
| Rate for Payer: Aetna Medicare |
$10.08
|
| Rate for Payer: Aetna Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$20.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$18.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$22.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.55
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Centivo All Commercial |
$17.14
|
| Rate for Payer: Centivo All Commercial |
$20.94
|
| Rate for Payer: Centivo All Commercial |
$19.04
|
| Rate for Payer: Cigna All Commercial |
$27.18
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: Cigna All Commercial |
$33.23
|
| Rate for Payer: CORVEL All Commercial |
$35.80
|
| Rate for Payer: CORVEL All Commercial |
$29.30
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$27.72
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Coventry All Commercial |
$33.88
|
| Rate for Payer: Encore All Commercial |
$29.00
|
| Rate for Payer: Encore All Commercial |
$35.44
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Frontpath All Commercial |
$28.98
|
| Rate for Payer: Frontpath All Commercial |
$35.42
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Humana ChoiceCare |
$27.21
|
| Rate for Payer: Humana ChoiceCare |
$33.25
|
| Rate for Payer: Humana Medicare |
$11.20
|
| Rate for Payer: Humana Medicare |
$12.32
|
| Rate for Payer: Humana Medicare |
$10.08
|
| Rate for Payer: Lucent All Commercial |
$19.04
|
| Rate for Payer: Lucent All Commercial |
$17.14
|
| Rate for Payer: Lucent All Commercial |
$20.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.65
|
| Rate for Payer: PHCS All Commercial |
$28.88
|
| Rate for Payer: PHCS All Commercial |
$23.62
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$23.89
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: PHP All Commercial |
$29.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Sagamore Health Network All Products |
$29.72
|
| Rate for Payer: Sagamore Health Network All Products |
$24.32
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care EPO |
$26.14
|
| Rate for Payer: Signature Care EPO |
$31.95
|
| Rate for Payer: Signature Care PPO |
$27.72
|
| Rate for Payer: Signature Care PPO |
$33.88
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$32.73
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
| Rate for Payer: United Healthcare Commercial |
$30.34
|
| Rate for Payer: United Healthcare Medicare |
$12.32
|
| Rate for Payer: United Healthcare Medicare |
$10.08
|
| Rate for Payer: United Healthcare Medicare |
$11.20
|
|
|
LACTATED RINGERS IV SOLP
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
4318
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$30.24
|
| Rate for Payer: Aetna Commercial |
$27.22
|
| Rate for Payer: Aetna Commercial |
$33.26
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: Cigna All Commercial |
$27.18
|
| Rate for Payer: Cigna All Commercial |
$33.23
|
| Rate for Payer: CORVEL All Commercial |
$35.80
|
| Rate for Payer: CORVEL All Commercial |
$29.30
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$27.72
|
| Rate for Payer: Coventry All Commercial |
$33.88
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Encore All Commercial |
$29.00
|
| Rate for Payer: Encore All Commercial |
$35.44
|
| Rate for Payer: Frontpath All Commercial |
$35.42
|
| Rate for Payer: Frontpath All Commercial |
$28.98
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Humana ChoiceCare |
$27.21
|
| Rate for Payer: Humana ChoiceCare |
$33.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.65
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHCS All Commercial |
$23.62
|
| Rate for Payer: PHCS All Commercial |
$28.88
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: PHP All Commercial |
$23.89
|
| Rate for Payer: PHP All Commercial |
$29.20
|
| Rate for Payer: Sagamore Health Network All Products |
$29.72
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Sagamore Health Network All Products |
$24.32
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care EPO |
$26.14
|
| Rate for Payer: Signature Care EPO |
$31.95
|
| Rate for Payer: Signature Care PPO |
$27.72
|
| Rate for Payer: Signature Care PPO |
$33.88
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
| Rate for Payer: United Healthcare Commercial |
$30.34
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
|
|
LACTOBACILLUS RHAMNOSUS GG 15 BILLION CELLS ORAL CPSP
|
Facility
|
IP
|
$3.98
|
|
|
Service Code
|
NDC 49100036374
|
| Hospital Charge Code |
164424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna All Commercial |
$3.43
|
| Rate for Payer: CORVEL All Commercial |
$3.70
|
| Rate for Payer: Coventry All Commercial |
$3.50
|
| Rate for Payer: Encore All Commercial |
$3.66
|
| Rate for Payer: Frontpath All Commercial |
$3.66
|
| Rate for Payer: Humana ChoiceCare |
$3.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.58
|
| Rate for Payer: PHCS All Commercial |
$2.98
|
| Rate for Payer: PHP All Commercial |
$3.02
|
| Rate for Payer: Sagamore Health Network All Products |
$3.07
|
| Rate for Payer: Signature Care EPO |
$3.30
|
| Rate for Payer: Signature Care PPO |
$3.50
|
| Rate for Payer: United Healthcare Commercial |
$3.13
|
|
|
LACTOBACILLUS RHAMNOSUS GG 15 BILLION CELLS ORAL CPSP
|
Facility
|
OP
|
$3.98
|
|
|
Service Code
|
NDC 49100036374
|
| Hospital Charge Code |
164424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Aetna Medicare |
$1.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.49
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.40
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Centivo All Commercial |
$2.16
|
| Rate for Payer: Cigna All Commercial |
$3.43
|
| Rate for Payer: CORVEL All Commercial |
$3.70
|
| Rate for Payer: Coventry All Commercial |
$3.50
|
| Rate for Payer: Encore All Commercial |
$3.66
|
| Rate for Payer: Frontpath All Commercial |
$3.66
|
| Rate for Payer: Humana ChoiceCare |
$3.43
|
| Rate for Payer: Humana Medicare |
$1.27
|
| Rate for Payer: Lucent All Commercial |
$2.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.58
|
| Rate for Payer: PHCS All Commercial |
$2.98
|
| Rate for Payer: PHP All Commercial |
$3.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.55
|
| Rate for Payer: Sagamore Health Network All Products |
$3.07
|
| Rate for Payer: Signature Care EPO |
$3.30
|
| Rate for Payer: Signature Care PPO |
$3.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.38
|
| Rate for Payer: United Healthcare Commercial |
$3.13
|
| Rate for Payer: United Healthcare Medicare |
$1.27
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLN
|
Facility
|
OP
|
$13.02
|
|
|
Service Code
|
NDC 00121115440
|
| Hospital Charge Code |
38245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.04 |
| Max. Negotiated Rate |
$12.11 |
| Rate for Payer: Aetna Commercial |
$10.99
|
| Rate for Payer: Aetna Medicare |
$4.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.58
|
| Rate for Payer: Cash Price |
$7.81
|
| Rate for Payer: Centivo All Commercial |
$7.08
|
| Rate for Payer: Cigna All Commercial |
$11.24
|
| Rate for Payer: CORVEL All Commercial |
$12.11
|
| Rate for Payer: Coventry All Commercial |
$11.46
|
| Rate for Payer: Encore All Commercial |
$11.98
|
| Rate for Payer: Frontpath All Commercial |
$11.98
|
| Rate for Payer: Humana ChoiceCare |
$11.25
|
| Rate for Payer: Humana Medicare |
$4.17
|
| Rate for Payer: Lucent All Commercial |
$7.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.72
|
| Rate for Payer: PHCS All Commercial |
$9.77
|
| Rate for Payer: PHP All Commercial |
$9.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.08
|
| Rate for Payer: Sagamore Health Network All Products |
$10.05
|
| Rate for Payer: Signature Care EPO |
$10.81
|
| Rate for Payer: Signature Care PPO |
$11.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.07
|
| Rate for Payer: United Healthcare Commercial |
$10.26
|
| Rate for Payer: United Healthcare Medicare |
$4.17
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLN
|
Facility
|
IP
|
$13.02
|
|
|
Service Code
|
NDC 00121115440
|
| Hospital Charge Code |
38245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$12.11 |
| Rate for Payer: Aetna Commercial |
$11.25
|
| Rate for Payer: Cash Price |
$7.81
|
| Rate for Payer: Cigna All Commercial |
$11.24
|
| Rate for Payer: CORVEL All Commercial |
$12.11
|
| Rate for Payer: Coventry All Commercial |
$11.46
|
| Rate for Payer: Encore All Commercial |
$11.98
|
| Rate for Payer: Frontpath All Commercial |
$11.98
|
| Rate for Payer: Humana ChoiceCare |
$11.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.72
|
| Rate for Payer: PHCS All Commercial |
$9.77
|
| Rate for Payer: PHP All Commercial |
$9.87
|
| Rate for Payer: Sagamore Health Network All Products |
$10.05
|
| Rate for Payer: Signature Care EPO |
$10.81
|
| Rate for Payer: Signature Care PPO |
$11.46
|
| Rate for Payer: United Healthcare Commercial |
$10.26
|
|
