|
LIDOCAINE HCL 2 % MM JELP
|
Facility
|
OP
|
$46.82
|
|
|
Service Code
|
NDC 25021067377
|
| Hospital Charge Code |
120006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$43.54 |
| Rate for Payer: Aetna Commercial |
$39.51
|
| Rate for Payer: Aetna Medicare |
$14.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$26.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.26
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.48
|
| Rate for Payer: Cash Price |
$28.09
|
| Rate for Payer: Cash Price |
$28.09
|
| Rate for Payer: Centivo All Commercial |
$25.47
|
| Rate for Payer: Cigna All Commercial |
$40.40
|
| Rate for Payer: CORVEL All Commercial |
$43.54
|
| Rate for Payer: Coventry All Commercial |
$41.20
|
| Rate for Payer: Encore All Commercial |
$43.09
|
| Rate for Payer: Frontpath All Commercial |
$43.07
|
| Rate for Payer: Humana ChoiceCare |
$40.43
|
| Rate for Payer: Humana Medicare |
$14.98
|
| Rate for Payer: Lucent All Commercial |
$25.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.13
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$35.11
|
| Rate for Payer: PHP All Commercial |
$35.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.26
|
| Rate for Payer: Sagamore Health Network All Products |
$36.14
|
| Rate for Payer: Signature Care EPO |
$38.86
|
| Rate for Payer: Signature Care PPO |
$41.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$39.79
|
| Rate for Payer: United Healthcare Commercial |
$36.89
|
| Rate for Payer: United Healthcare Medicare |
$14.98
|
|
|
LIDOCAINE HCL 2 % MM JELP
|
Facility
|
IP
|
$46.82
|
|
|
Service Code
|
NDC 25021067377
|
| Hospital Charge Code |
120006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.11 |
| Max. Negotiated Rate |
$43.54 |
| Rate for Payer: Aetna Commercial |
$40.45
|
| Rate for Payer: Cash Price |
$28.09
|
| Rate for Payer: Cigna All Commercial |
$40.40
|
| Rate for Payer: CORVEL All Commercial |
$43.54
|
| Rate for Payer: Coventry All Commercial |
$41.20
|
| Rate for Payer: Encore All Commercial |
$43.09
|
| Rate for Payer: Frontpath All Commercial |
$43.07
|
| Rate for Payer: Humana ChoiceCare |
$40.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.13
|
| Rate for Payer: PHCS All Commercial |
$35.11
|
| Rate for Payer: PHP All Commercial |
$35.51
|
| Rate for Payer: Sagamore Health Network All Products |
$36.14
|
| Rate for Payer: Signature Care EPO |
$38.86
|
| Rate for Payer: Signature Care PPO |
$41.20
|
| Rate for Payer: United Healthcare Commercial |
$36.89
|
|
|
LIDOCAINE HCL 2 % MM JELP
|
Facility
|
IP
|
$53.20
|
|
|
Service Code
|
NDC 76329301305
|
| Hospital Charge Code |
120006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.90 |
| Max. Negotiated Rate |
$49.48 |
| Rate for Payer: Aetna Commercial |
$45.96
|
| Rate for Payer: Cash Price |
$31.92
|
| Rate for Payer: Cigna All Commercial |
$45.91
|
| Rate for Payer: CORVEL All Commercial |
$49.48
|
| Rate for Payer: Coventry All Commercial |
$46.82
|
| Rate for Payer: Encore All Commercial |
$48.97
|
| Rate for Payer: Frontpath All Commercial |
$48.94
|
| Rate for Payer: Humana ChoiceCare |
$45.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$47.88
|
| Rate for Payer: PHCS All Commercial |
$39.90
|
| Rate for Payer: PHP All Commercial |
$40.35
|
| Rate for Payer: Sagamore Health Network All Products |
$41.07
|
| Rate for Payer: Signature Care EPO |
$44.16
|
| Rate for Payer: Signature Care PPO |
$46.82
|
| Rate for Payer: United Healthcare Commercial |
$41.92
|
|
|
LIDOCAINE HCL 2 % MM JELP
|
Facility
|
OP
|
$53.20
|
|
|
Service Code
|
NDC 76329301305
|
| Hospital Charge Code |
120006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$49.48 |
| Rate for Payer: Aetna Commercial |
$44.90
|
| Rate for Payer: Aetna Medicare |
$17.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$30.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$33.26
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$19.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.73
|
| Rate for Payer: Cash Price |
$31.92
|
| Rate for Payer: Cash Price |
$31.92
|
| Rate for Payer: Centivo All Commercial |
$28.94
|
| Rate for Payer: Cigna All Commercial |
$45.91
|
| Rate for Payer: CORVEL All Commercial |
$49.48
|
| Rate for Payer: Coventry All Commercial |
$46.82
|
| Rate for Payer: Encore All Commercial |
$48.97
|
| Rate for Payer: Frontpath All Commercial |
$48.94
|
| Rate for Payer: Humana ChoiceCare |
$45.95
|
| Rate for Payer: Humana Medicare |
$17.02
|
| Rate for Payer: Lucent All Commercial |
$28.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$47.88
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$39.90
|
| Rate for Payer: PHP All Commercial |
$40.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$20.75
|
| Rate for Payer: Sagamore Health Network All Products |
$41.07
|
| Rate for Payer: Signature Care EPO |
$44.16
|
| Rate for Payer: Signature Care PPO |
$46.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$45.22
|
| Rate for Payer: United Healthcare Commercial |
$41.92
|
| Rate for Payer: United Healthcare Medicare |
$17.02
|
|
|
LIDOCAINE HCL 2 % MM JELP
|
Facility
|
IP
|
$25.83
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
120006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.37 |
| Max. Negotiated Rate |
$24.02 |
| Rate for Payer: Aetna Commercial |
$22.32
|
| Rate for Payer: Cash Price |
$15.50
|
| 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: Lutheran Preferred All Commercial |
$23.25
|
| Rate for Payer: PHCS All Commercial |
$19.37
|
| Rate for Payer: PHP All Commercial |
$19.59
|
| 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: United Healthcare Commercial |
$20.35
|
|
|
LIDOCAINE HCL 2 % MM SOLN
|
Facility
|
IP
|
$36.96
|
|
|
Service Code
|
NDC 00121495040
|
| Hospital Charge Code |
111639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$34.37 |
| Rate for Payer: Aetna Commercial |
$31.93
|
| Rate for Payer: Cash Price |
$22.18
|
| Rate for Payer: Cigna All Commercial |
$31.90
|
| Rate for Payer: CORVEL All Commercial |
$34.37
|
| Rate for Payer: Coventry All Commercial |
$32.52
|
| Rate for Payer: Encore All Commercial |
$34.02
|
| Rate for Payer: Frontpath All Commercial |
$34.00
|
| Rate for Payer: Humana ChoiceCare |
$31.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.26
|
| Rate for Payer: PHCS All Commercial |
$27.72
|
| Rate for Payer: PHP All Commercial |
$28.03
|
| Rate for Payer: Sagamore Health Network All Products |
$28.53
|
| Rate for Payer: Signature Care EPO |
$30.68
|
| Rate for Payer: Signature Care PPO |
$32.52
|
| Rate for Payer: United Healthcare Commercial |
$29.12
|
|
|
LIDOCAINE HCL 2 % MM SOLN
|
Facility
|
OP
|
$36.96
|
|
|
Service Code
|
NDC 00121495040
|
| Hospital Charge Code |
111639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.46 |
| Max. Negotiated Rate |
$34.37 |
| Rate for Payer: Aetna Commercial |
$31.19
|
| Rate for Payer: Aetna Medicare |
$11.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$21.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.01
|
| Rate for Payer: Cash Price |
$22.18
|
| Rate for Payer: Centivo All Commercial |
$20.11
|
| Rate for Payer: Cigna All Commercial |
$31.90
|
| Rate for Payer: CORVEL All Commercial |
$34.37
|
| Rate for Payer: Coventry All Commercial |
$32.52
|
| Rate for Payer: Encore All Commercial |
$34.02
|
| Rate for Payer: Frontpath All Commercial |
$34.00
|
| Rate for Payer: Humana ChoiceCare |
$31.92
|
| Rate for Payer: Humana Medicare |
$11.83
|
| Rate for Payer: Lucent All Commercial |
$20.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.26
|
| Rate for Payer: PHCS All Commercial |
$27.72
|
| Rate for Payer: PHP All Commercial |
$28.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.41
|
| Rate for Payer: Sagamore Health Network All Products |
$28.53
|
| Rate for Payer: Signature Care EPO |
$30.68
|
| Rate for Payer: Signature Care PPO |
$32.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.42
|
| Rate for Payer: United Healthcare Commercial |
$29.12
|
| Rate for Payer: United Healthcare Medicare |
$11.83
|
|
|
LIDOCAINE HCL 2 % MM SOLN
|
Facility
|
IP
|
$70.70
|
|
|
Service Code
|
NDC 00054350049
|
| Hospital Charge Code |
111639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.02 |
| Max. Negotiated Rate |
$65.75 |
| Rate for Payer: Aetna Commercial |
$61.08
|
| Rate for Payer: Cash Price |
$42.42
|
| Rate for Payer: Cigna All Commercial |
$61.01
|
| Rate for Payer: CORVEL All Commercial |
$65.75
|
| Rate for Payer: Coventry All Commercial |
$62.22
|
| Rate for Payer: Encore All Commercial |
$65.08
|
| Rate for Payer: Frontpath All Commercial |
$65.04
|
| Rate for Payer: Humana ChoiceCare |
$61.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$63.63
|
| Rate for Payer: PHCS All Commercial |
$53.02
|
| Rate for Payer: PHP All Commercial |
$53.62
|
| Rate for Payer: Sagamore Health Network All Products |
$54.58
|
| Rate for Payer: Signature Care EPO |
$58.68
|
| Rate for Payer: Signature Care PPO |
$62.22
|
| Rate for Payer: United Healthcare Commercial |
$55.71
|
|
|
LIDOCAINE HCL 2 % MM SOLN
|
Facility
|
OP
|
$70.70
|
|
|
Service Code
|
NDC 00054350049
|
| Hospital Charge Code |
111639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.92 |
| Max. Negotiated Rate |
$65.75 |
| Rate for Payer: Aetna Commercial |
$59.67
|
| Rate for Payer: Aetna Medicare |
$22.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$40.60
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$44.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.89
|
| Rate for Payer: Cash Price |
$42.42
|
| Rate for Payer: Centivo All Commercial |
$38.46
|
| Rate for Payer: Cigna All Commercial |
$61.01
|
| Rate for Payer: CORVEL All Commercial |
$65.75
|
| Rate for Payer: Coventry All Commercial |
$62.22
|
| Rate for Payer: Encore All Commercial |
$65.08
|
| Rate for Payer: Frontpath All Commercial |
$65.04
|
| Rate for Payer: Humana ChoiceCare |
$61.06
|
| Rate for Payer: Humana Medicare |
$22.62
|
| Rate for Payer: Lucent All Commercial |
$38.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$63.63
|
| Rate for Payer: PHCS All Commercial |
$53.02
|
| Rate for Payer: PHP All Commercial |
$53.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$27.57
|
| Rate for Payer: Sagamore Health Network All Products |
$54.58
|
| Rate for Payer: Signature Care EPO |
$58.68
|
| Rate for Payer: Signature Care PPO |
$62.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$60.09
|
| Rate for Payer: United Healthcare Commercial |
$55.71
|
| Rate for Payer: United Healthcare Medicare |
$22.62
|
|
|
LIDOCAINE HCL 2 % MM SOLN
|
Facility
|
OP
|
$36.96
|
|
|
Service Code
|
NDC 00121495015
|
| Hospital Charge Code |
111639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.46 |
| Max. Negotiated Rate |
$34.37 |
| Rate for Payer: Aetna Commercial |
$31.19
|
| Rate for Payer: Aetna Medicare |
$11.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$21.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.01
|
| Rate for Payer: Cash Price |
$22.18
|
| Rate for Payer: Centivo All Commercial |
$20.11
|
| Rate for Payer: Cigna All Commercial |
$31.90
|
| Rate for Payer: CORVEL All Commercial |
$34.37
|
| Rate for Payer: Coventry All Commercial |
$32.52
|
| Rate for Payer: Encore All Commercial |
$34.02
|
| Rate for Payer: Frontpath All Commercial |
$34.00
|
| Rate for Payer: Humana ChoiceCare |
$31.92
|
| Rate for Payer: Humana Medicare |
$11.83
|
| Rate for Payer: Lucent All Commercial |
$20.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.26
|
| Rate for Payer: PHCS All Commercial |
$27.72
|
| Rate for Payer: PHP All Commercial |
$28.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.41
|
| Rate for Payer: Sagamore Health Network All Products |
$28.53
|
| Rate for Payer: Signature Care EPO |
$30.68
|
| Rate for Payer: Signature Care PPO |
$32.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.42
|
| Rate for Payer: United Healthcare Commercial |
$29.12
|
| Rate for Payer: United Healthcare Medicare |
$11.83
|
|
|
LIDOCAINE HCL 2 % MM SOLN
|
Facility
|
IP
|
$36.96
|
|
|
Service Code
|
NDC 00121495015
|
| Hospital Charge Code |
111639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$34.37 |
| Rate for Payer: Aetna Commercial |
$31.93
|
| Rate for Payer: Cash Price |
$22.18
|
| Rate for Payer: Cigna All Commercial |
$31.90
|
| Rate for Payer: CORVEL All Commercial |
$34.37
|
| Rate for Payer: Coventry All Commercial |
$32.52
|
| Rate for Payer: Encore All Commercial |
$34.02
|
| Rate for Payer: Frontpath All Commercial |
$34.00
|
| Rate for Payer: Humana ChoiceCare |
$31.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.26
|
| Rate for Payer: PHCS All Commercial |
$27.72
|
| Rate for Payer: PHP All Commercial |
$28.03
|
| Rate for Payer: Sagamore Health Network All Products |
$28.53
|
| Rate for Payer: Signature Care EPO |
$30.68
|
| Rate for Payer: Signature Care PPO |
$32.52
|
| Rate for Payer: United Healthcare Commercial |
$29.12
|
|
|
LIDOCAINE HCL 2 % MM SOLN (UD)
|
Facility
|
OP
|
$5.04
|
|
|
Service Code
|
NDC 50383077517
|
| Hospital Charge Code |
800672
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$4.25
|
| Rate for Payer: Aetna Medicare |
$1.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.15
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.77
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Centivo All Commercial |
$2.74
|
| Rate for Payer: Cigna All Commercial |
$4.35
|
| Rate for Payer: CORVEL All Commercial |
$4.69
|
| Rate for Payer: Coventry All Commercial |
$4.44
|
| Rate for Payer: Encore All Commercial |
$4.64
|
| Rate for Payer: Frontpath All Commercial |
$4.64
|
| Rate for Payer: Humana ChoiceCare |
$4.35
|
| Rate for Payer: Humana Medicare |
$1.61
|
| Rate for Payer: Lucent All Commercial |
$2.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.54
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$3.78
|
| Rate for Payer: PHP All Commercial |
$3.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.97
|
| Rate for Payer: Sagamore Health Network All Products |
$3.89
|
| Rate for Payer: Signature Care EPO |
$4.18
|
| Rate for Payer: Signature Care PPO |
$4.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.28
|
| Rate for Payer: United Healthcare Commercial |
$3.97
|
| Rate for Payer: United Healthcare Medicare |
$1.61
|
|
|
LIDOCAINE HCL 2 % MM SOLN (UD)
|
Facility
|
IP
|
$5.04
|
|
|
Service Code
|
NDC 50383077517
|
| Hospital Charge Code |
800672
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.78 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$4.35
|
| Rate for Payer: Cash Price |
$3.02
|
| Rate for Payer: Cigna All Commercial |
$4.35
|
| Rate for Payer: CORVEL All Commercial |
$4.69
|
| Rate for Payer: Coventry All Commercial |
$4.44
|
| Rate for Payer: Encore All Commercial |
$4.64
|
| Rate for Payer: Frontpath All Commercial |
$4.64
|
| Rate for Payer: Humana ChoiceCare |
$4.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.54
|
| Rate for Payer: PHCS All Commercial |
$3.78
|
| Rate for Payer: PHP All Commercial |
$3.82
|
| Rate for Payer: Sagamore Health Network All Products |
$3.89
|
| Rate for Payer: Signature Care EPO |
$4.18
|
| Rate for Payer: Signature Care PPO |
$4.44
|
| Rate for Payer: United Healthcare Commercial |
$3.97
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MM SOLN
|
Facility
|
IP
|
$266.00
|
|
|
Service Code
|
NDC 00054350547
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$199.50 |
| Max. Negotiated Rate |
$247.38 |
| Rate for Payer: Aetna Commercial |
$229.82
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna All Commercial |
$229.56
|
| Rate for Payer: CORVEL All Commercial |
$247.38
|
| Rate for Payer: Coventry All Commercial |
$234.08
|
| Rate for Payer: Encore All Commercial |
$244.85
|
| Rate for Payer: Frontpath All Commercial |
$244.72
|
| Rate for Payer: Humana ChoiceCare |
$229.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$239.40
|
| Rate for Payer: PHCS All Commercial |
$199.50
|
| Rate for Payer: PHP All Commercial |
$201.73
|
| Rate for Payer: Sagamore Health Network All Products |
$205.35
|
| Rate for Payer: Signature Care EPO |
$220.78
|
| Rate for Payer: Signature Care PPO |
$234.08
|
| Rate for Payer: United Healthcare Commercial |
$209.61
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MM SOLN
|
Facility
|
OP
|
$266.00
|
|
|
Service Code
|
NDC 00054350547
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$247.38 |
| Rate for Payer: Aetna Commercial |
$224.50
|
| Rate for Payer: Aetna Medicare |
$85.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$82.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$152.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$166.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$97.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$93.63
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Centivo All Commercial |
$144.70
|
| Rate for Payer: Cigna All Commercial |
$229.56
|
| Rate for Payer: CORVEL All Commercial |
$247.38
|
| Rate for Payer: Coventry All Commercial |
$234.08
|
| Rate for Payer: Encore All Commercial |
$244.85
|
| Rate for Payer: Frontpath All Commercial |
$244.72
|
| Rate for Payer: Humana ChoiceCare |
$229.74
|
| Rate for Payer: Humana Medicare |
$85.12
|
| Rate for Payer: Lucent All Commercial |
$144.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$239.40
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$199.50
|
| Rate for Payer: PHP All Commercial |
$201.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$103.74
|
| Rate for Payer: Sagamore Health Network All Products |
$205.35
|
| Rate for Payer: Signature Care EPO |
$220.78
|
| Rate for Payer: Signature Care PPO |
$234.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$226.10
|
| Rate for Payer: United Healthcare Commercial |
$209.61
|
| Rate for Payer: United Healthcare Medicare |
$85.12
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MM SOLN FOR ENT USE (CAMERON)
|
Facility
|
IP
|
$606.00
|
|
|
Service Code
|
NDC 000543505
|
| Hospital Charge Code |
14010004450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$454.50 |
| Max. Negotiated Rate |
$563.58 |
| Rate for Payer: Aetna Commercial |
$523.58
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cigna All Commercial |
$522.98
|
| Rate for Payer: CORVEL All Commercial |
$563.58
|
| Rate for Payer: Coventry All Commercial |
$533.28
|
| Rate for Payer: Encore All Commercial |
$557.82
|
| Rate for Payer: Frontpath All Commercial |
$557.52
|
| Rate for Payer: Humana ChoiceCare |
$523.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$545.40
|
| Rate for Payer: PHCS All Commercial |
$454.50
|
| Rate for Payer: PHP All Commercial |
$459.59
|
| Rate for Payer: Sagamore Health Network All Products |
$467.83
|
| Rate for Payer: Signature Care EPO |
$502.98
|
| Rate for Payer: Signature Care PPO |
$533.28
|
| Rate for Payer: United Healthcare Commercial |
$477.53
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MM SOLN FOR ENT USE (CAMERON)
|
Facility
|
OP
|
$606.00
|
|
|
Service Code
|
NDC 000543505
|
| Hospital Charge Code |
14010004450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$563.58 |
| Rate for Payer: Aetna Commercial |
$511.46
|
| Rate for Payer: Aetna Medicare |
$193.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$187.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$348.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$378.81
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$223.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$213.31
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Cash Price |
$363.60
|
| Rate for Payer: Centivo All Commercial |
$329.66
|
| Rate for Payer: Cigna All Commercial |
$522.98
|
| Rate for Payer: CORVEL All Commercial |
$563.58
|
| Rate for Payer: Coventry All Commercial |
$533.28
|
| Rate for Payer: Encore All Commercial |
$557.82
|
| Rate for Payer: Frontpath All Commercial |
$557.52
|
| Rate for Payer: Humana ChoiceCare |
$523.40
|
| Rate for Payer: Humana Medicare |
$193.92
|
| Rate for Payer: Lucent All Commercial |
$329.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$545.40
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$454.50
|
| Rate for Payer: PHP All Commercial |
$459.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$236.34
|
| Rate for Payer: Sagamore Health Network All Products |
$467.83
|
| Rate for Payer: Signature Care EPO |
$502.98
|
| Rate for Payer: Signature Care PPO |
$533.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$515.10
|
| Rate for Payer: United Healthcare Commercial |
$477.53
|
| Rate for Payer: United Healthcare Medicare |
$193.92
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRG
|
Facility
|
OP
|
$47.85
|
|
|
Service Code
|
NDC 76329339001
|
| Hospital Charge Code |
4459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$44.50 |
| Rate for Payer: Aetna Commercial |
$40.38
|
| Rate for Payer: Aetna Medicare |
$15.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$27.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.91
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.84
|
| Rate for Payer: Cash Price |
$28.71
|
| Rate for Payer: Cash Price |
$28.71
|
| Rate for Payer: Centivo All Commercial |
$26.03
|
| Rate for Payer: Cigna All Commercial |
$41.29
|
| Rate for Payer: CORVEL All Commercial |
$44.50
|
| Rate for Payer: Coventry All Commercial |
$42.10
|
| Rate for Payer: Encore All Commercial |
$44.04
|
| Rate for Payer: Frontpath All Commercial |
$44.02
|
| Rate for Payer: Humana ChoiceCare |
$41.32
|
| Rate for Payer: Humana Medicare |
$15.31
|
| Rate for Payer: Lucent All Commercial |
$26.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.06
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$35.88
|
| Rate for Payer: PHP All Commercial |
$36.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.66
|
| Rate for Payer: Sagamore Health Network All Products |
$36.94
|
| Rate for Payer: Signature Care EPO |
$39.71
|
| Rate for Payer: Signature Care PPO |
$42.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.67
|
| Rate for Payer: United Healthcare Commercial |
$37.70
|
| Rate for Payer: United Healthcare Medicare |
$15.31
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRG
|
Facility
|
IP
|
$47.85
|
|
|
Service Code
|
NDC 76329339001
|
| Hospital Charge Code |
4459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.88 |
| Max. Negotiated Rate |
$44.50 |
| Rate for Payer: Aetna Commercial |
$41.34
|
| Rate for Payer: Cash Price |
$28.71
|
| Rate for Payer: Cigna All Commercial |
$41.29
|
| Rate for Payer: CORVEL All Commercial |
$44.50
|
| Rate for Payer: Coventry All Commercial |
$42.10
|
| Rate for Payer: Encore All Commercial |
$44.04
|
| Rate for Payer: Frontpath All Commercial |
$44.02
|
| Rate for Payer: Humana ChoiceCare |
$41.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.06
|
| Rate for Payer: PHCS All Commercial |
$35.88
|
| Rate for Payer: PHP All Commercial |
$36.29
|
| Rate for Payer: Sagamore Health Network All Products |
$36.94
|
| Rate for Payer: Signature Care EPO |
$39.71
|
| Rate for Payer: Signature Care PPO |
$42.10
|
| Rate for Payer: United Healthcare Commercial |
$37.70
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRG - FOR PAIN IVPB (CAMERON)
|
Facility
|
OP
|
$50.89
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
14010004459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.78 |
| Max. Negotiated Rate |
$47.33 |
| Rate for Payer: Aetna Commercial |
$42.95
|
| Rate for Payer: Aetna Medicare |
$16.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$29.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.91
|
| Rate for Payer: Cash Price |
$30.53
|
| Rate for Payer: Centivo All Commercial |
$27.68
|
| Rate for Payer: Cigna All Commercial |
$43.92
|
| Rate for Payer: CORVEL All Commercial |
$47.33
|
| Rate for Payer: Coventry All Commercial |
$44.78
|
| Rate for Payer: Encore All Commercial |
$46.84
|
| Rate for Payer: Frontpath All Commercial |
$46.82
|
| Rate for Payer: Humana ChoiceCare |
$43.95
|
| Rate for Payer: Humana Medicare |
$16.28
|
| Rate for Payer: Lucent All Commercial |
$27.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.80
|
| Rate for Payer: PHCS All Commercial |
$38.17
|
| Rate for Payer: PHP All Commercial |
$38.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.85
|
| Rate for Payer: Sagamore Health Network All Products |
$39.29
|
| Rate for Payer: Signature Care EPO |
$42.24
|
| Rate for Payer: Signature Care PPO |
$44.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$43.26
|
| Rate for Payer: United Healthcare Commercial |
$40.10
|
| Rate for Payer: United Healthcare Medicare |
$16.28
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRG - FOR PAIN IVPB (CAMERON)
|
Facility
|
IP
|
$50.89
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
14010004459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.17 |
| Max. Negotiated Rate |
$47.33 |
| Rate for Payer: Aetna Commercial |
$43.97
|
| Rate for Payer: Cash Price |
$30.53
|
| Rate for Payer: Cigna All Commercial |
$43.92
|
| Rate for Payer: CORVEL All Commercial |
$47.33
|
| Rate for Payer: Coventry All Commercial |
$44.78
|
| Rate for Payer: Encore All Commercial |
$46.84
|
| Rate for Payer: Frontpath All Commercial |
$46.82
|
| Rate for Payer: Humana ChoiceCare |
$43.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.80
|
| Rate for Payer: PHCS All Commercial |
$38.17
|
| Rate for Payer: PHP All Commercial |
$38.59
|
| Rate for Payer: Sagamore Health Network All Products |
$39.29
|
| Rate for Payer: Signature Care EPO |
$42.24
|
| Rate for Payer: Signature Care PPO |
$44.78
|
| Rate for Payer: United Healthcare Commercial |
$40.10
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
103888
|
|
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 |
$21.77
|
| Rate for Payer: Aetna Commercial |
$69.71
|
| Rate for Payer: Aetna Medicare |
$8.25
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Aetna Medicare |
$26.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$25.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$47.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$51.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.08
|
| Rate for Payer: Cash Price |
$49.56
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$15.48
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Centivo All Commercial |
$44.93
|
| Rate for Payer: Centivo All Commercial |
$14.03
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$22.26
|
| Rate for Payer: Cigna All Commercial |
$71.28
|
| Rate for Payer: CORVEL All Commercial |
$76.82
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$23.99
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Coventry All Commercial |
$22.70
|
| Rate for Payer: Coventry All Commercial |
$72.69
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Encore All Commercial |
$76.03
|
| Rate for Payer: Encore All Commercial |
$23.74
|
| Rate for Payer: Frontpath All Commercial |
$23.73
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Frontpath All Commercial |
$75.99
|
| Rate for Payer: Humana ChoiceCare |
$22.28
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana ChoiceCare |
$71.34
|
| Rate for Payer: Humana Medicare |
$8.25
|
| Rate for Payer: Humana Medicare |
$26.43
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$14.03
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lucent All Commercial |
$44.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.34
|
| Rate for Payer: PHCS All Commercial |
$61.95
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHCS All Commercial |
$19.35
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$19.56
|
| Rate for Payer: PHP All Commercial |
$62.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.06
|
| Rate for Payer: Sagamore Health Network All Products |
$19.91
|
| Rate for Payer: Sagamore Health Network All Products |
$63.77
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$21.41
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care EPO |
$68.56
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$72.69
|
| Rate for Payer: Signature Care PPO |
$22.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.93
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$70.21
|
| Rate for Payer: United Healthcare Commercial |
$20.33
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$65.09
|
| Rate for Payer: United Healthcare Medicare |
$26.43
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
| Rate for Payer: United Healthcare Medicare |
$8.25
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Aetna Commercial |
$22.29
|
| Rate for Payer: Aetna Commercial |
$71.37
|
| Rate for Payer: Cash Price |
$49.56
|
| Rate for Payer: Cash Price |
$15.48
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$71.28
|
| Rate for Payer: Cigna All Commercial |
$22.26
|
| Rate for Payer: CORVEL All Commercial |
$23.99
|
| Rate for Payer: CORVEL All Commercial |
$76.82
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$72.69
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Coventry All Commercial |
$22.70
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Encore All Commercial |
$23.74
|
| Rate for Payer: Encore All Commercial |
$76.03
|
| Rate for Payer: Frontpath All Commercial |
$23.73
|
| Rate for Payer: Frontpath All Commercial |
$75.99
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$71.34
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana ChoiceCare |
$22.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$61.95
|
| Rate for Payer: PHCS All Commercial |
$19.35
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$62.64
|
| Rate for Payer: PHP All Commercial |
$19.56
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$63.77
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Sagamore Health Network All Products |
$19.91
|
| Rate for Payer: Signature Care EPO |
$21.41
|
| Rate for Payer: Signature Care EPO |
$68.56
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$22.70
|
| Rate for Payer: Signature Care PPO |
$72.69
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$65.09
|
| Rate for Payer: United Healthcare Commercial |
$20.33
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN
|
Facility
|
OP
|
$25.13
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.79 |
| Max. Negotiated Rate |
$23.37 |
| Rate for Payer: Aetna Commercial |
$21.21
|
| Rate for Payer: Aetna Commercial |
$17.31
|
| Rate for Payer: Aetna Medicare |
$6.56
|
| Rate for Payer: Aetna Medicare |
$8.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.79
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.85
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Cash Price |
$12.31
|
| Rate for Payer: Centivo All Commercial |
$13.67
|
| Rate for Payer: Centivo All Commercial |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$17.70
|
| Rate for Payer: Cigna All Commercial |
$21.69
|
| Rate for Payer: CORVEL All Commercial |
$19.07
|
| Rate for Payer: CORVEL All Commercial |
$23.37
|
| Rate for Payer: Coventry All Commercial |
$18.05
|
| Rate for Payer: Coventry All Commercial |
$22.11
|
| Rate for Payer: Encore All Commercial |
$18.88
|
| Rate for Payer: Encore All Commercial |
$23.13
|
| Rate for Payer: Frontpath All Commercial |
$23.12
|
| Rate for Payer: Frontpath All Commercial |
$18.87
|
| Rate for Payer: Humana ChoiceCare |
$21.70
|
| Rate for Payer: Humana ChoiceCare |
$17.71
|
| Rate for Payer: Humana Medicare |
$8.04
|
| Rate for Payer: Humana Medicare |
$6.56
|
| Rate for Payer: Lucent All Commercial |
$11.16
|
| Rate for Payer: Lucent All Commercial |
$13.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.46
|
| Rate for Payer: PHCS All Commercial |
$18.85
|
| Rate for Payer: PHCS All Commercial |
$15.38
|
| Rate for Payer: PHP All Commercial |
$15.55
|
| Rate for Payer: PHP All Commercial |
$19.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.80
|
| Rate for Payer: Sagamore Health Network All Products |
$15.83
|
| Rate for Payer: Sagamore Health Network All Products |
$19.40
|
| Rate for Payer: Signature Care EPO |
$20.86
|
| Rate for Payer: Signature Care EPO |
$17.02
|
| Rate for Payer: Signature Care PPO |
$18.05
|
| Rate for Payer: Signature Care PPO |
$22.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.43
|
| Rate for Payer: United Healthcare Commercial |
$16.16
|
| Rate for Payer: United Healthcare Commercial |
$19.80
|
| Rate for Payer: United Healthcare Medicare |
$6.56
|
| Rate for Payer: United Healthcare Medicare |
$8.04
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN
|
Facility
|
IP
|
$25.13
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.85 |
| Max. Negotiated Rate |
$23.37 |
| Rate for Payer: Aetna Commercial |
$21.71
|
| Rate for Payer: Aetna Commercial |
$17.72
|
| Rate for Payer: Cash Price |
$12.31
|
| Rate for Payer: Cash Price |
$15.08
|
| Rate for Payer: Cigna All Commercial |
$17.70
|
| Rate for Payer: Cigna All Commercial |
$21.69
|
| Rate for Payer: CORVEL All Commercial |
$19.07
|
| Rate for Payer: CORVEL All Commercial |
$23.37
|
| Rate for Payer: Coventry All Commercial |
$22.11
|
| Rate for Payer: Coventry All Commercial |
$18.05
|
| Rate for Payer: Encore All Commercial |
$23.13
|
| Rate for Payer: Encore All Commercial |
$18.88
|
| Rate for Payer: Frontpath All Commercial |
$18.87
|
| Rate for Payer: Frontpath All Commercial |
$23.12
|
| Rate for Payer: Humana ChoiceCare |
$17.71
|
| Rate for Payer: Humana ChoiceCare |
$21.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.62
|
| Rate for Payer: PHCS All Commercial |
$18.85
|
| Rate for Payer: PHCS All Commercial |
$15.38
|
| Rate for Payer: PHP All Commercial |
$15.55
|
| Rate for Payer: PHP All Commercial |
$19.06
|
| Rate for Payer: Sagamore Health Network All Products |
$19.40
|
| Rate for Payer: Sagamore Health Network All Products |
$15.83
|
| Rate for Payer: Signature Care EPO |
$20.86
|
| Rate for Payer: Signature Care EPO |
$17.02
|
| Rate for Payer: Signature Care PPO |
$18.05
|
| Rate for Payer: Signature Care PPO |
$22.11
|
| Rate for Payer: United Healthcare Commercial |
$16.16
|
| Rate for Payer: United Healthcare Commercial |
$19.80
|
|
