|
LEVOTHYROXINE 200 MCG IV SOLR
|
Facility
|
IP
|
$1,001.45
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
4418
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$751.09 |
| Max. Negotiated Rate |
$931.35 |
| Rate for Payer: Aetna Commercial |
$865.25
|
| Rate for Payer: Cash Price |
$600.87
|
| Rate for Payer: Cigna All Commercial |
$864.25
|
| Rate for Payer: CORVEL All Commercial |
$931.35
|
| Rate for Payer: Coventry All Commercial |
$881.28
|
| Rate for Payer: Encore All Commercial |
$921.83
|
| Rate for Payer: Frontpath All Commercial |
$921.33
|
| Rate for Payer: Humana ChoiceCare |
$864.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$901.30
|
| Rate for Payer: PHCS All Commercial |
$751.09
|
| Rate for Payer: PHP All Commercial |
$759.50
|
| Rate for Payer: Sagamore Health Network All Products |
$773.12
|
| Rate for Payer: Signature Care EPO |
$831.20
|
| Rate for Payer: Signature Care PPO |
$881.28
|
| Rate for Payer: United Healthcare Commercial |
$789.14
|
|
|
LEVOTHYROXINE 200 MCG IV SOLR
|
Facility
|
OP
|
$1,001.45
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
4418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$310.45 |
| Max. Negotiated Rate |
$931.35 |
| Rate for Payer: Aetna Commercial |
$845.22
|
| Rate for Payer: Aetna Medicare |
$320.46
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$310.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$575.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$626.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$368.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$352.51
|
| Rate for Payer: Cash Price |
$600.87
|
| Rate for Payer: Centivo All Commercial |
$544.79
|
| Rate for Payer: Cigna All Commercial |
$864.25
|
| Rate for Payer: CORVEL All Commercial |
$931.35
|
| Rate for Payer: Coventry All Commercial |
$881.28
|
| Rate for Payer: Encore All Commercial |
$921.83
|
| Rate for Payer: Frontpath All Commercial |
$921.33
|
| Rate for Payer: Humana ChoiceCare |
$864.95
|
| Rate for Payer: Humana Medicare |
$320.46
|
| Rate for Payer: Lucent All Commercial |
$544.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$901.30
|
| Rate for Payer: PHCS All Commercial |
$751.09
|
| Rate for Payer: PHP All Commercial |
$759.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$390.57
|
| Rate for Payer: Sagamore Health Network All Products |
$773.12
|
| Rate for Payer: Signature Care EPO |
$831.20
|
| Rate for Payer: Signature Care PPO |
$881.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$851.23
|
| Rate for Payer: United Healthcare Commercial |
$789.14
|
| Rate for Payer: United Healthcare Medicare |
$320.46
|
|
|
LEVOTHYROXINE 25 MCG ORAL TAB
|
Facility
|
IP
|
$3.42
|
|
|
Service Code
|
NDC 51079044420
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Aetna Commercial |
$2.95
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cigna All Commercial |
$2.95
|
| Rate for Payer: CORVEL All Commercial |
$3.18
|
| Rate for Payer: Coventry All Commercial |
$3.01
|
| Rate for Payer: Encore All Commercial |
$3.14
|
| Rate for Payer: Frontpath All Commercial |
$3.14
|
| Rate for Payer: Humana ChoiceCare |
$2.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.07
|
| Rate for Payer: PHCS All Commercial |
$2.56
|
| Rate for Payer: PHP All Commercial |
$2.59
|
| Rate for Payer: Sagamore Health Network All Products |
$2.64
|
| Rate for Payer: Signature Care EPO |
$2.84
|
| Rate for Payer: Signature Care PPO |
$3.01
|
| Rate for Payer: United Healthcare Commercial |
$2.69
|
|
|
LEVOTHYROXINE 25 MCG ORAL TAB
|
Facility
|
OP
|
$3.42
|
|
|
Service Code
|
NDC 51079044420
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Aetna Commercial |
$2.88
|
| Rate for Payer: Aetna Medicare |
$1.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.20
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Centivo All Commercial |
$1.86
|
| Rate for Payer: Cigna All Commercial |
$2.95
|
| Rate for Payer: CORVEL All Commercial |
$3.18
|
| Rate for Payer: Coventry All Commercial |
$3.01
|
| Rate for Payer: Encore All Commercial |
$3.14
|
| Rate for Payer: Frontpath All Commercial |
$3.14
|
| Rate for Payer: Humana ChoiceCare |
$2.95
|
| Rate for Payer: Humana Medicare |
$1.09
|
| Rate for Payer: Lucent All Commercial |
$1.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.07
|
| Rate for Payer: PHCS All Commercial |
$2.56
|
| Rate for Payer: PHP All Commercial |
$2.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.33
|
| Rate for Payer: Sagamore Health Network All Products |
$2.64
|
| Rate for Payer: Signature Care EPO |
$2.84
|
| Rate for Payer: Signature Care PPO |
$3.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.90
|
| Rate for Payer: United Healthcare Commercial |
$2.69
|
| Rate for Payer: United Healthcare Medicare |
$1.09
|
|
|
LEVOTHYROXINE 88 MCG ORAL TAB
|
Facility
|
IP
|
$2.90
|
|
|
Service Code
|
NDC 00904695261
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna Commercial |
$2.50
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Cigna All Commercial |
$2.50
|
| Rate for Payer: CORVEL All Commercial |
$2.70
|
| Rate for Payer: Coventry All Commercial |
$2.55
|
| Rate for Payer: Encore All Commercial |
$2.67
|
| Rate for Payer: Frontpath All Commercial |
$2.67
|
| Rate for Payer: Humana ChoiceCare |
$2.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.61
|
| Rate for Payer: PHCS All Commercial |
$2.17
|
| Rate for Payer: PHP All Commercial |
$2.20
|
| Rate for Payer: Sagamore Health Network All Products |
$2.24
|
| Rate for Payer: Signature Care EPO |
$2.41
|
| Rate for Payer: Signature Care PPO |
$2.55
|
| Rate for Payer: United Healthcare Commercial |
$2.28
|
|
|
LEVOTHYROXINE 88 MCG ORAL TAB
|
Facility
|
OP
|
$2.90
|
|
|
Service Code
|
NDC 00904695261
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna Commercial |
$2.45
|
| Rate for Payer: Aetna Medicare |
$0.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.02
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Centivo All Commercial |
$1.58
|
| Rate for Payer: Cigna All Commercial |
$2.50
|
| Rate for Payer: CORVEL All Commercial |
$2.70
|
| Rate for Payer: Coventry All Commercial |
$2.55
|
| Rate for Payer: Encore All Commercial |
$2.67
|
| Rate for Payer: Frontpath All Commercial |
$2.67
|
| Rate for Payer: Humana ChoiceCare |
$2.50
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Lucent All Commercial |
$1.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.61
|
| Rate for Payer: PHCS All Commercial |
$2.17
|
| Rate for Payer: PHP All Commercial |
$2.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.13
|
| Rate for Payer: Sagamore Health Network All Products |
$2.24
|
| Rate for Payer: Signature Care EPO |
$2.41
|
| Rate for Payer: Signature Care PPO |
$2.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.46
|
| Rate for Payer: United Healthcare Commercial |
$2.28
|
| Rate for Payer: United Healthcare Medicare |
$0.93
|
|
|
LIDOCAINE 4 % TOP PTMD
|
Facility
|
OP
|
$7.40
|
|
|
Service Code
|
NDC 00536120207
|
| Hospital Charge Code |
110425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Aetna Commercial |
$6.24
|
| Rate for Payer: Aetna Medicare |
$2.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.60
|
| Rate for Payer: Cash Price |
$4.44
|
| Rate for Payer: Centivo All Commercial |
$4.03
|
| Rate for Payer: Cigna All Commercial |
$6.39
|
| Rate for Payer: CORVEL All Commercial |
$6.88
|
| Rate for Payer: Coventry All Commercial |
$6.51
|
| Rate for Payer: Encore All Commercial |
$6.81
|
| Rate for Payer: Frontpath All Commercial |
$6.81
|
| Rate for Payer: Humana ChoiceCare |
$6.39
|
| Rate for Payer: Humana Medicare |
$2.37
|
| Rate for Payer: Lucent All Commercial |
$4.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.66
|
| Rate for Payer: PHCS All Commercial |
$5.55
|
| Rate for Payer: PHP All Commercial |
$5.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.89
|
| Rate for Payer: Sagamore Health Network All Products |
$5.71
|
| Rate for Payer: Signature Care EPO |
$6.14
|
| Rate for Payer: Signature Care PPO |
$6.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.29
|
| Rate for Payer: United Healthcare Commercial |
$5.83
|
| Rate for Payer: United Healthcare Medicare |
$2.37
|
|
|
LIDOCAINE 4 % TOP PTMD
|
Facility
|
IP
|
$7.40
|
|
|
Service Code
|
NDC 00536120207
|
| Hospital Charge Code |
110425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.55 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Aetna Commercial |
$6.39
|
| Rate for Payer: Cash Price |
$4.44
|
| Rate for Payer: Cigna All Commercial |
$6.39
|
| Rate for Payer: CORVEL All Commercial |
$6.88
|
| Rate for Payer: Coventry All Commercial |
$6.51
|
| Rate for Payer: Encore All Commercial |
$6.81
|
| Rate for Payer: Frontpath All Commercial |
$6.81
|
| Rate for Payer: Humana ChoiceCare |
$6.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.66
|
| Rate for Payer: PHCS All Commercial |
$5.55
|
| Rate for Payer: PHP All Commercial |
$5.61
|
| Rate for Payer: Sagamore Health Network All Products |
$5.71
|
| Rate for Payer: Signature Care EPO |
$6.14
|
| Rate for Payer: Signature Care PPO |
$6.51
|
| Rate for Payer: United Healthcare Commercial |
$5.83
|
|
|
LIDOCAINE 5 % TOP PTMD
|
Facility
|
OP
|
$29.52
|
|
|
Service Code
|
NDC 00591352530
|
| Hospital Charge Code |
28203
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.15 |
| Max. Negotiated Rate |
$27.45 |
| Rate for Payer: Aetna Commercial |
$24.91
|
| Rate for Payer: Aetna Medicare |
$9.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.95
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.39
|
| Rate for Payer: Cash Price |
$17.71
|
| Rate for Payer: Centivo All Commercial |
$16.06
|
| Rate for Payer: Cigna All Commercial |
$25.47
|
| Rate for Payer: CORVEL All Commercial |
$27.45
|
| Rate for Payer: Coventry All Commercial |
$25.98
|
| Rate for Payer: Encore All Commercial |
$27.17
|
| Rate for Payer: Frontpath All Commercial |
$27.16
|
| Rate for Payer: Humana ChoiceCare |
$25.50
|
| Rate for Payer: Humana Medicare |
$9.45
|
| Rate for Payer: Lucent All Commercial |
$16.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.57
|
| Rate for Payer: PHCS All Commercial |
$22.14
|
| Rate for Payer: PHP All Commercial |
$22.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.51
|
| Rate for Payer: Sagamore Health Network All Products |
$22.79
|
| Rate for Payer: Signature Care EPO |
$24.50
|
| Rate for Payer: Signature Care PPO |
$25.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25.09
|
| Rate for Payer: United Healthcare Commercial |
$23.26
|
| Rate for Payer: United Healthcare Medicare |
$9.45
|
|
|
LIDOCAINE 5 % TOP PTMD
|
Facility
|
IP
|
$29.52
|
|
|
Service Code
|
NDC 00591352530
|
| Hospital Charge Code |
28203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.14 |
| Max. Negotiated Rate |
$27.45 |
| Rate for Payer: Aetna Commercial |
$25.50
|
| Rate for Payer: Cash Price |
$17.71
|
| Rate for Payer: Cigna All Commercial |
$25.47
|
| Rate for Payer: CORVEL All Commercial |
$27.45
|
| Rate for Payer: Coventry All Commercial |
$25.98
|
| Rate for Payer: Encore All Commercial |
$27.17
|
| Rate for Payer: Frontpath All Commercial |
$27.16
|
| Rate for Payer: Humana ChoiceCare |
$25.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.57
|
| Rate for Payer: PHCS All Commercial |
$22.14
|
| Rate for Payer: PHP All Commercial |
$22.39
|
| Rate for Payer: Sagamore Health Network All Products |
$22.79
|
| Rate for Payer: Signature Care EPO |
$24.50
|
| Rate for Payer: Signature Care PPO |
$25.98
|
| Rate for Payer: United Healthcare Commercial |
$23.26
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
|
IP
|
$36.54
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.41 |
| Max. Negotiated Rate |
$33.98 |
| Rate for Payer: Aetna Commercial |
$31.57
|
| Rate for Payer: Aetna Commercial |
$22.44
|
| Rate for Payer: Aetna Commercial |
$31.81
|
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$21.92
|
| Rate for Payer: Cash Price |
$15.58
|
| Rate for Payer: Cash Price |
$22.09
|
| Rate for Payer: Cigna All Commercial |
$31.53
|
| Rate for Payer: Cigna All Commercial |
$31.78
|
| Rate for Payer: Cigna All Commercial |
$22.41
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$34.24
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$24.15
|
| Rate for Payer: CORVEL All Commercial |
$33.98
|
| Rate for Payer: Coventry All Commercial |
$32.40
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Coventry All Commercial |
$32.16
|
| Rate for Payer: Coventry All Commercial |
$22.85
|
| Rate for Payer: Encore All Commercial |
$23.91
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Encore All Commercial |
$33.89
|
| Rate for Payer: Encore All Commercial |
$33.64
|
| Rate for Payer: Frontpath All Commercial |
$33.62
|
| Rate for Payer: Frontpath All Commercial |
$23.89
|
| Rate for Payer: Frontpath All Commercial |
$33.87
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$31.80
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana ChoiceCare |
$22.43
|
| Rate for Payer: Humana ChoiceCare |
$31.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.14
|
| Rate for Payer: PHCS All Commercial |
$27.61
|
| Rate for Payer: PHCS All Commercial |
$19.48
|
| Rate for Payer: PHCS All Commercial |
$27.41
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$27.71
|
| Rate for Payer: PHP All Commercial |
$27.92
|
| Rate for Payer: PHP All Commercial |
$19.70
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$20.05
|
| Rate for Payer: Sagamore Health Network All Products |
$28.21
|
| Rate for Payer: Sagamore Health Network All Products |
$28.43
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care EPO |
$30.56
|
| Rate for Payer: Signature Care EPO |
$30.33
|
| Rate for Payer: Signature Care EPO |
$21.56
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$22.85
|
| Rate for Payer: Signature Care PPO |
$32.16
|
| Rate for Payer: Signature Care PPO |
$32.40
|
| Rate for Payer: United Healthcare Commercial |
$20.46
|
| Rate for Payer: United Healthcare Commercial |
$29.01
|
| Rate for Payer: United Healthcare Commercial |
$28.79
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10427
|
|
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 Commercial |
$30.84
|
| Rate for Payer: Aetna Commercial |
$31.08
|
| Rate for Payer: Aetna Commercial |
$21.92
|
| Rate for Payer: Aetna Medicare |
$11.78
|
| Rate for Payer: Aetna Medicare |
$8.31
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Aetna Medicare |
$11.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$21.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$20.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.02
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.14
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$15.58
|
| Rate for Payer: Cash Price |
$22.09
|
| Rate for Payer: Cash Price |
$21.92
|
| Rate for Payer: Centivo All Commercial |
$20.03
|
| Rate for Payer: Centivo All Commercial |
$14.13
|
| Rate for Payer: Centivo All Commercial |
$19.88
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$22.41
|
| Rate for Payer: Cigna All Commercial |
$31.53
|
| Rate for Payer: Cigna All Commercial |
$31.78
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$33.98
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$34.24
|
| Rate for Payer: CORVEL All Commercial |
$24.15
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Coventry All Commercial |
$32.16
|
| Rate for Payer: Coventry All Commercial |
$32.40
|
| Rate for Payer: Coventry All Commercial |
$22.85
|
| Rate for Payer: Encore All Commercial |
$33.64
|
| Rate for Payer: Encore All Commercial |
$23.91
|
| Rate for Payer: Encore All Commercial |
$33.89
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$33.87
|
| Rate for Payer: Frontpath All Commercial |
$23.89
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Frontpath All Commercial |
$33.62
|
| Rate for Payer: Humana ChoiceCare |
$31.56
|
| Rate for Payer: Humana ChoiceCare |
$31.80
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana ChoiceCare |
$22.43
|
| Rate for Payer: Humana Medicare |
$11.78
|
| Rate for Payer: Humana Medicare |
$11.69
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Humana Medicare |
$8.31
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lucent All Commercial |
$14.13
|
| Rate for Payer: Lucent All Commercial |
$19.88
|
| Rate for Payer: Lucent All Commercial |
$20.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.14
|
| Rate for Payer: PHCS All Commercial |
$19.48
|
| Rate for Payer: PHCS All Commercial |
$27.61
|
| Rate for Payer: PHCS All Commercial |
$27.41
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$27.71
|
| Rate for Payer: PHP All Commercial |
$19.70
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$27.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Sagamore Health Network All Products |
$28.43
|
| Rate for Payer: Sagamore Health Network All Products |
$28.21
|
| Rate for Payer: Sagamore Health Network All Products |
$20.05
|
| Rate for Payer: Signature Care EPO |
$30.33
|
| Rate for Payer: Signature Care EPO |
$30.56
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care EPO |
$21.56
|
| Rate for Payer: Signature Care PPO |
$22.85
|
| Rate for Payer: Signature Care PPO |
$32.16
|
| Rate for Payer: Signature Care PPO |
$32.40
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22.07
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.06
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$28.79
|
| Rate for Payer: United Healthcare Commercial |
$20.46
|
| Rate for Payer: United Healthcare Commercial |
$29.01
|
| Rate for Payer: United Healthcare Medicare |
$8.31
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
| Rate for Payer: United Healthcare Medicare |
$11.78
|
| Rate for Payer: United Healthcare Medicare |
$11.69
|
|
|
LIDOCAINE-EPINEPHRINE 2 %-1:100,000 INJ SOLN
|
Facility
|
OP
|
$37.24
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.54 |
| Max. Negotiated Rate |
$34.63 |
| Rate for Payer: Aetna Commercial |
$31.43
|
| Rate for Payer: Aetna Medicare |
$11.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$21.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.11
|
| Rate for Payer: Cash Price |
$22.34
|
| Rate for Payer: Centivo All Commercial |
$20.26
|
| Rate for Payer: Cigna All Commercial |
$32.14
|
| Rate for Payer: CORVEL All Commercial |
$34.63
|
| Rate for Payer: Coventry All Commercial |
$32.77
|
| Rate for Payer: Encore All Commercial |
$34.28
|
| Rate for Payer: Frontpath All Commercial |
$34.26
|
| Rate for Payer: Humana ChoiceCare |
$32.16
|
| Rate for Payer: Humana Medicare |
$11.92
|
| Rate for Payer: Lucent All Commercial |
$20.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.52
|
| Rate for Payer: PHCS All Commercial |
$27.93
|
| Rate for Payer: PHP All Commercial |
$28.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.52
|
| Rate for Payer: Sagamore Health Network All Products |
$28.75
|
| Rate for Payer: Signature Care EPO |
$30.91
|
| Rate for Payer: Signature Care PPO |
$32.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.65
|
| Rate for Payer: United Healthcare Commercial |
$29.35
|
| Rate for Payer: United Healthcare Medicare |
$11.92
|
|
|
LIDOCAINE-EPINEPHRINE 2 %-1:100,000 INJ SOLN
|
Facility
|
IP
|
$37.24
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.93 |
| Max. Negotiated Rate |
$34.63 |
| Rate for Payer: Aetna Commercial |
$32.18
|
| Rate for Payer: Cash Price |
$22.34
|
| Rate for Payer: Cigna All Commercial |
$32.14
|
| Rate for Payer: CORVEL All Commercial |
$34.63
|
| Rate for Payer: Coventry All Commercial |
$32.77
|
| Rate for Payer: Encore All Commercial |
$34.28
|
| Rate for Payer: Frontpath All Commercial |
$34.26
|
| Rate for Payer: Humana ChoiceCare |
$32.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.52
|
| Rate for Payer: PHCS All Commercial |
$27.93
|
| Rate for Payer: PHP All Commercial |
$28.24
|
| Rate for Payer: Sagamore Health Network All Products |
$28.75
|
| Rate for Payer: Signature Care EPO |
$30.91
|
| Rate for Payer: Signature Care PPO |
$32.77
|
| Rate for Payer: United Healthcare Commercial |
$29.35
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJ SOLN
|
Facility
|
OP
|
$101.01
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
15985
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.31 |
| Max. Negotiated Rate |
$93.94 |
| Rate for Payer: Aetna Commercial |
$85.25
|
| Rate for Payer: Aetna Medicare |
$32.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$58.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$63.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$37.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35.56
|
| Rate for Payer: Cash Price |
$60.61
|
| Rate for Payer: Centivo All Commercial |
$54.95
|
| Rate for Payer: Cigna All Commercial |
$87.17
|
| Rate for Payer: CORVEL All Commercial |
$93.94
|
| Rate for Payer: Coventry All Commercial |
$88.89
|
| Rate for Payer: Encore All Commercial |
$92.98
|
| Rate for Payer: Frontpath All Commercial |
$92.93
|
| Rate for Payer: Humana ChoiceCare |
$87.24
|
| Rate for Payer: Humana Medicare |
$32.32
|
| Rate for Payer: Lucent All Commercial |
$54.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.91
|
| Rate for Payer: PHCS All Commercial |
$75.76
|
| Rate for Payer: PHP All Commercial |
$76.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.39
|
| Rate for Payer: Sagamore Health Network All Products |
$77.98
|
| Rate for Payer: Signature Care EPO |
$83.84
|
| Rate for Payer: Signature Care PPO |
$88.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$85.86
|
| Rate for Payer: United Healthcare Commercial |
$79.60
|
| Rate for Payer: United Healthcare Medicare |
$32.32
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJ SOLN
|
Facility
|
IP
|
$101.01
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
15985
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.76 |
| Max. Negotiated Rate |
$93.94 |
| Rate for Payer: Aetna Commercial |
$87.27
|
| Rate for Payer: Cash Price |
$60.61
|
| Rate for Payer: Cigna All Commercial |
$87.17
|
| Rate for Payer: CORVEL All Commercial |
$93.94
|
| Rate for Payer: Coventry All Commercial |
$88.89
|
| Rate for Payer: Encore All Commercial |
$92.98
|
| Rate for Payer: Frontpath All Commercial |
$92.93
|
| Rate for Payer: Humana ChoiceCare |
$87.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.91
|
| Rate for Payer: PHCS All Commercial |
$75.76
|
| Rate for Payer: PHP All Commercial |
$76.61
|
| Rate for Payer: Sagamore Health Network All Products |
$77.98
|
| Rate for Payer: Signature Care EPO |
$83.84
|
| Rate for Payer: Signature Care PPO |
$88.89
|
| Rate for Payer: United Healthcare Commercial |
$79.60
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJ SOLN
|
Facility
|
IP
|
$71.68
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
15956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.76 |
| Max. Negotiated Rate |
$66.66 |
| Rate for Payer: Aetna Commercial |
$61.93
|
| Rate for Payer: Cash Price |
$43.01
|
| Rate for Payer: Cigna All Commercial |
$61.86
|
| Rate for Payer: CORVEL All Commercial |
$66.66
|
| Rate for Payer: Coventry All Commercial |
$63.08
|
| Rate for Payer: Encore All Commercial |
$65.98
|
| Rate for Payer: Frontpath All Commercial |
$65.95
|
| Rate for Payer: Humana ChoiceCare |
$61.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$64.51
|
| Rate for Payer: PHCS All Commercial |
$53.76
|
| Rate for Payer: PHP All Commercial |
$54.36
|
| Rate for Payer: Sagamore Health Network All Products |
$55.34
|
| Rate for Payer: Signature Care EPO |
$59.49
|
| Rate for Payer: Signature Care PPO |
$63.08
|
| Rate for Payer: United Healthcare Commercial |
$56.48
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJ SOLN
|
Facility
|
OP
|
$71.68
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
15956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.22 |
| Max. Negotiated Rate |
$66.66 |
| Rate for Payer: Aetna Commercial |
$60.50
|
| Rate for Payer: Aetna Medicare |
$22.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$41.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$44.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.23
|
| Rate for Payer: Cash Price |
$43.01
|
| Rate for Payer: Centivo All Commercial |
$38.99
|
| Rate for Payer: Cigna All Commercial |
$61.86
|
| Rate for Payer: CORVEL All Commercial |
$66.66
|
| Rate for Payer: Coventry All Commercial |
$63.08
|
| Rate for Payer: Encore All Commercial |
$65.98
|
| Rate for Payer: Frontpath All Commercial |
$65.95
|
| Rate for Payer: Humana ChoiceCare |
$61.91
|
| Rate for Payer: Humana Medicare |
$22.94
|
| Rate for Payer: Lucent All Commercial |
$38.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$64.51
|
| Rate for Payer: PHCS All Commercial |
$53.76
|
| Rate for Payer: PHP All Commercial |
$54.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$27.96
|
| Rate for Payer: Sagamore Health Network All Products |
$55.34
|
| Rate for Payer: Signature Care EPO |
$59.49
|
| Rate for Payer: Signature Care PPO |
$63.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$60.93
|
| Rate for Payer: United Healthcare Commercial |
$56.48
|
| Rate for Payer: United Healthcare Medicare |
$22.94
|
|
|
LIDOCAINE-EPINEPHRINE-TETRACAINE (LET) SOLN 3 ML
|
Facility
|
IP
|
$99.04
|
|
|
Service Code
|
NDC 70092161144
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.28 |
| Max. Negotiated Rate |
$92.10 |
| Rate for Payer: Aetna Commercial |
$85.57
|
| Rate for Payer: Cash Price |
$59.42
|
| Rate for Payer: Cigna All Commercial |
$85.47
|
| Rate for Payer: CORVEL All Commercial |
$92.10
|
| Rate for Payer: Coventry All Commercial |
$87.15
|
| Rate for Payer: Encore All Commercial |
$91.16
|
| Rate for Payer: Frontpath All Commercial |
$91.11
|
| Rate for Payer: Humana ChoiceCare |
$85.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$89.13
|
| Rate for Payer: PHCS All Commercial |
$74.28
|
| Rate for Payer: PHP All Commercial |
$75.11
|
| Rate for Payer: Sagamore Health Network All Products |
$76.46
|
| Rate for Payer: Signature Care EPO |
$82.20
|
| Rate for Payer: Signature Care PPO |
$87.15
|
| Rate for Payer: United Healthcare Commercial |
$78.04
|
|
|
LIDOCAINE-EPINEPHRINE-TETRACAINE (LET) SOLN 3 ML
|
Facility
|
OP
|
$99.04
|
|
|
Service Code
|
NDC 70092161144
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$92.10 |
| Rate for Payer: Aetna Commercial |
$83.59
|
| Rate for Payer: Aetna Medicare |
$31.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$30.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$56.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$61.91
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$36.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$34.86
|
| Rate for Payer: Cash Price |
$59.42
|
| Rate for Payer: Cash Price |
$59.42
|
| Rate for Payer: Centivo All Commercial |
$53.88
|
| Rate for Payer: Cigna All Commercial |
$85.47
|
| Rate for Payer: CORVEL All Commercial |
$92.10
|
| Rate for Payer: Coventry All Commercial |
$87.15
|
| Rate for Payer: Encore All Commercial |
$91.16
|
| Rate for Payer: Frontpath All Commercial |
$91.11
|
| Rate for Payer: Humana ChoiceCare |
$85.54
|
| Rate for Payer: Humana Medicare |
$31.69
|
| Rate for Payer: Lucent All Commercial |
$53.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$89.13
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$74.28
|
| Rate for Payer: PHP All Commercial |
$75.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$38.62
|
| Rate for Payer: Sagamore Health Network All Products |
$76.46
|
| Rate for Payer: Signature Care EPO |
$82.20
|
| Rate for Payer: Signature Care PPO |
$87.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$84.18
|
| Rate for Payer: United Healthcare Commercial |
$78.04
|
| Rate for Payer: United Healthcare Medicare |
$31.69
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4452
|
|
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
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4452
|
|
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
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJ SOLN
|
Facility
|
IP
|
$25.90
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.43 |
| Max. Negotiated Rate |
$24.09 |
| Rate for Payer: Aetna Commercial |
$22.38
|
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$15.54
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$22.35
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$24.09
|
| Rate for Payer: Coventry All Commercial |
$22.79
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$23.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Frontpath All Commercial |
$23.83
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana ChoiceCare |
$22.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.31
|
| Rate for Payer: PHCS All Commercial |
$19.43
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$19.64
|
| Rate for Payer: Sagamore Health Network All Products |
$19.99
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$21.50
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$22.79
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$20.41
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJ SOLN
|
Facility
|
OP
|
$25.90
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.03 |
| Max. Negotiated Rate |
$24.09 |
| Rate for Payer: Aetna Commercial |
$21.86
|
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Aetna Medicare |
$8.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.03
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.87
|
| 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 |
$16.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.12
|
| Rate for Payer: Cash Price |
$15.54
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$14.09
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$22.35
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$24.09
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Coventry All Commercial |
$22.79
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Encore All Commercial |
$23.84
|
| Rate for Payer: Frontpath All Commercial |
$23.83
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$22.37
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$8.29
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lucent All Commercial |
$14.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$19.43
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$19.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.10
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Sagamore Health Network All Products |
$19.99
|
| Rate for Payer: Signature Care EPO |
$21.50
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$22.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$20.41
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
| Rate for Payer: United Healthcare Medicare |
$8.29
|
|
|
LIDOCAINE HCL 2 % MM JELP
|
Facility
|
OP
|
$25.83
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
120006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.01 |
| Max. Negotiated Rate |
$24.02 |
| Rate for Payer: Aetna Commercial |
$21.80
|
| Rate for Payer: Aetna Medicare |
$8.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.15
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.51
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.09
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Centivo All Commercial |
$14.05
|
| Rate for Payer: Cigna All Commercial |
$22.29
|
| Rate for Payer: CORVEL All Commercial |
$24.02
|
| Rate for Payer: Coventry All Commercial |
$22.73
|
| Rate for Payer: Encore All Commercial |
$23.78
|
| Rate for Payer: Frontpath All Commercial |
$23.76
|
| Rate for Payer: Humana ChoiceCare |
$22.31
|
| Rate for Payer: Humana Medicare |
$8.27
|
| Rate for Payer: Lucent All Commercial |
$14.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.25
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$19.37
|
| Rate for Payer: PHP All Commercial |
$19.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.07
|
| Rate for Payer: Sagamore Health Network All Products |
$19.94
|
| Rate for Payer: Signature Care EPO |
$21.44
|
| Rate for Payer: Signature Care PPO |
$22.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.96
|
| Rate for Payer: United Healthcare Commercial |
$20.35
|
| Rate for Payer: United Healthcare Medicare |
$8.27
|
|
