|
LIDOCAINE (PF) 20 MG/ML (2 %) IV SOLN
|
Facility
|
OP
|
$24.54
|
|
|
Service Code
|
NDC 63323020805
|
| Hospital Charge Code |
118084
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.61 |
| Max. Negotiated Rate |
$22.82 |
| Rate for Payer: Aetna Commercial |
$20.71
|
| Rate for Payer: Aetna Medicare |
$7.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.34
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.64
|
| Rate for Payer: Cash Price |
$14.72
|
| Rate for Payer: Cash Price |
$14.72
|
| Rate for Payer: Centivo All Commercial |
$13.35
|
| Rate for Payer: Cigna All Commercial |
$21.17
|
| Rate for Payer: CORVEL All Commercial |
$22.82
|
| Rate for Payer: Coventry All Commercial |
$21.59
|
| Rate for Payer: Encore All Commercial |
$22.58
|
| Rate for Payer: Frontpath All Commercial |
$22.57
|
| Rate for Payer: Humana ChoiceCare |
$21.19
|
| Rate for Payer: Humana Medicare |
$7.85
|
| Rate for Payer: Lucent All Commercial |
$13.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.08
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$18.40
|
| Rate for Payer: PHP All Commercial |
$18.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.57
|
| Rate for Payer: Sagamore Health Network All Products |
$18.94
|
| Rate for Payer: Signature Care EPO |
$20.36
|
| Rate for Payer: Signature Care PPO |
$21.59
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.85
|
| Rate for Payer: United Healthcare Commercial |
$19.33
|
| Rate for Payer: United Healthcare Medicare |
$7.85
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) IV SOLN
|
Facility
|
IP
|
$24.54
|
|
|
Service Code
|
NDC 63323020805
|
| Hospital Charge Code |
118084
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$22.82 |
| Rate for Payer: Aetna Commercial |
$21.20
|
| Rate for Payer: Cash Price |
$14.72
|
| Rate for Payer: Cigna All Commercial |
$21.17
|
| Rate for Payer: CORVEL All Commercial |
$22.82
|
| Rate for Payer: Coventry All Commercial |
$21.59
|
| Rate for Payer: Encore All Commercial |
$22.58
|
| Rate for Payer: Frontpath All Commercial |
$22.57
|
| Rate for Payer: Humana ChoiceCare |
$21.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.08
|
| Rate for Payer: PHCS All Commercial |
$18.40
|
| Rate for Payer: PHP All Commercial |
$18.61
|
| Rate for Payer: Sagamore Health Network All Products |
$18.94
|
| Rate for Payer: Signature Care EPO |
$20.36
|
| Rate for Payer: Signature Care PPO |
$21.59
|
| Rate for Payer: United Healthcare Commercial |
$19.33
|
|
|
LIDOCAINE (PF) 4 MG/ML (0.4 %) IV SOLP
|
Facility
|
OP
|
$59.50
|
|
|
Service Code
|
HCPCS J2002
|
| Hospital Charge Code |
14868
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.45 |
| Max. Negotiated Rate |
$55.34 |
| Rate for Payer: Aetna Commercial |
$50.22
|
| Rate for Payer: Aetna Medicare |
$19.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$34.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$37.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.90
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.94
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Centivo All Commercial |
$32.37
|
| Rate for Payer: Cigna All Commercial |
$51.35
|
| Rate for Payer: CORVEL All Commercial |
$55.34
|
| Rate for Payer: Coventry All Commercial |
$52.36
|
| Rate for Payer: Encore All Commercial |
$54.77
|
| Rate for Payer: Frontpath All Commercial |
$54.74
|
| Rate for Payer: Humana ChoiceCare |
$51.39
|
| Rate for Payer: Humana Medicare |
$19.04
|
| Rate for Payer: Lucent All Commercial |
$32.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.55
|
| Rate for Payer: PHCS All Commercial |
$44.62
|
| Rate for Payer: PHP All Commercial |
$45.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.20
|
| Rate for Payer: Sagamore Health Network All Products |
$45.93
|
| Rate for Payer: Signature Care EPO |
$49.38
|
| Rate for Payer: Signature Care PPO |
$52.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$50.58
|
| Rate for Payer: United Healthcare Commercial |
$46.89
|
| Rate for Payer: United Healthcare Medicare |
$19.04
|
|
|
LIDOCAINE (PF) 4 MG/ML (0.4 %) IV SOLP
|
Facility
|
IP
|
$59.50
|
|
|
Service Code
|
HCPCS J2002
|
| Hospital Charge Code |
14868
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.62 |
| Max. Negotiated Rate |
$55.34 |
| Rate for Payer: Aetna Commercial |
$51.41
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna All Commercial |
$51.35
|
| Rate for Payer: CORVEL All Commercial |
$55.34
|
| Rate for Payer: Coventry All Commercial |
$52.36
|
| Rate for Payer: Encore All Commercial |
$54.77
|
| Rate for Payer: Frontpath All Commercial |
$54.74
|
| Rate for Payer: Humana ChoiceCare |
$51.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$53.55
|
| Rate for Payer: PHCS All Commercial |
$44.62
|
| Rate for Payer: PHP All Commercial |
$45.12
|
| Rate for Payer: Sagamore Health Network All Products |
$45.93
|
| Rate for Payer: Signature Care EPO |
$49.38
|
| Rate for Payer: Signature Care PPO |
$52.36
|
| Rate for Payer: United Healthcare Commercial |
$46.89
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
105635
|
|
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 (PF) 5 MG/ML (0.5 %) INJ SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
105635
|
|
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-PRILOCAINE 2.5-2.5 % TOP CREA
|
Facility
|
IP
|
$57.58
|
|
|
Service Code
|
NDC 00168035755
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.18 |
| Max. Negotiated Rate |
$53.54 |
| Rate for Payer: Aetna Commercial |
$49.74
|
| Rate for Payer: Cash Price |
$34.55
|
| Rate for Payer: Cigna All Commercial |
$49.69
|
| Rate for Payer: CORVEL All Commercial |
$53.54
|
| Rate for Payer: Coventry All Commercial |
$50.67
|
| Rate for Payer: Encore All Commercial |
$53.00
|
| Rate for Payer: Frontpath All Commercial |
$52.97
|
| Rate for Payer: Humana ChoiceCare |
$49.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.82
|
| Rate for Payer: PHCS All Commercial |
$43.18
|
| Rate for Payer: PHP All Commercial |
$43.66
|
| Rate for Payer: Sagamore Health Network All Products |
$44.45
|
| Rate for Payer: Signature Care EPO |
$47.79
|
| Rate for Payer: Signature Care PPO |
$50.67
|
| Rate for Payer: United Healthcare Commercial |
$45.37
|
|
|
LIDOCAINE-PRILOCAINE 2.5-2.5 % TOP CREA
|
Facility
|
OP
|
$57.58
|
|
|
Service Code
|
NDC 00168035755
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$53.54 |
| Rate for Payer: Aetna Commercial |
$48.59
|
| Rate for Payer: Aetna Medicare |
$18.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$33.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$35.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.27
|
| Rate for Payer: Cash Price |
$34.55
|
| Rate for Payer: Centivo All Commercial |
$31.32
|
| Rate for Payer: Cigna All Commercial |
$49.69
|
| Rate for Payer: CORVEL All Commercial |
$53.54
|
| Rate for Payer: Coventry All Commercial |
$50.67
|
| Rate for Payer: Encore All Commercial |
$53.00
|
| Rate for Payer: Frontpath All Commercial |
$52.97
|
| Rate for Payer: Humana ChoiceCare |
$49.73
|
| Rate for Payer: Humana Medicare |
$18.42
|
| Rate for Payer: Lucent All Commercial |
$31.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.82
|
| Rate for Payer: PHCS All Commercial |
$43.18
|
| Rate for Payer: PHP All Commercial |
$43.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.45
|
| Rate for Payer: Sagamore Health Network All Products |
$44.45
|
| Rate for Payer: Signature Care EPO |
$47.79
|
| Rate for Payer: Signature Care PPO |
$50.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$48.94
|
| Rate for Payer: United Healthcare Commercial |
$45.37
|
| Rate for Payer: United Healthcare Medicare |
$18.42
|
|
|
LIDOCAINE-RACEPINEP-TETRACAINE 4-0.05-0.5 % TOP GEL
|
Facility
|
OP
|
$99.04
|
|
|
Service Code
|
NDC 70092161144
|
| Hospital Charge Code |
182360
|
|
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-RACEPINEP-TETRACAINE 4-0.05-0.5 % TOP GEL
|
Facility
|
IP
|
$99.04
|
|
|
Service Code
|
NDC 70092161144
|
| Hospital Charge Code |
182360
|
|
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
|
|
|
LINEZOLID 600 MG ORAL TAB
|
Facility
|
IP
|
$19.63
|
|
|
Service Code
|
NDC 00904655304
|
| Hospital Charge Code |
28224
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$18.25 |
| Rate for Payer: Aetna Commercial |
$16.96
|
| Rate for Payer: Cash Price |
$11.78
|
| Rate for Payer: Cigna All Commercial |
$16.94
|
| Rate for Payer: CORVEL All Commercial |
$18.25
|
| Rate for Payer: Coventry All Commercial |
$17.27
|
| Rate for Payer: Encore All Commercial |
$18.07
|
| Rate for Payer: Frontpath All Commercial |
$18.06
|
| Rate for Payer: Humana ChoiceCare |
$16.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.67
|
| Rate for Payer: PHCS All Commercial |
$14.72
|
| Rate for Payer: PHP All Commercial |
$14.89
|
| Rate for Payer: Sagamore Health Network All Products |
$15.15
|
| Rate for Payer: Signature Care EPO |
$16.29
|
| Rate for Payer: Signature Care PPO |
$17.27
|
| Rate for Payer: United Healthcare Commercial |
$15.47
|
|
|
LINEZOLID 600 MG ORAL TAB
|
Facility
|
OP
|
$19.63
|
|
|
Service Code
|
NDC 00904655304
|
| Hospital Charge Code |
28224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$18.25 |
| Rate for Payer: Aetna Commercial |
$16.57
|
| Rate for Payer: Aetna Medicare |
$6.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.91
|
| Rate for Payer: Cash Price |
$11.78
|
| Rate for Payer: Centivo All Commercial |
$10.68
|
| Rate for Payer: Cigna All Commercial |
$16.94
|
| Rate for Payer: CORVEL All Commercial |
$18.25
|
| Rate for Payer: Coventry All Commercial |
$17.27
|
| Rate for Payer: Encore All Commercial |
$18.07
|
| Rate for Payer: Frontpath All Commercial |
$18.06
|
| Rate for Payer: Humana ChoiceCare |
$16.95
|
| Rate for Payer: Humana Medicare |
$6.28
|
| Rate for Payer: Lucent All Commercial |
$10.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.67
|
| Rate for Payer: PHCS All Commercial |
$14.72
|
| Rate for Payer: PHP All Commercial |
$14.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.65
|
| Rate for Payer: Sagamore Health Network All Products |
$15.15
|
| Rate for Payer: Signature Care EPO |
$16.29
|
| Rate for Payer: Signature Care PPO |
$17.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.68
|
| Rate for Payer: United Healthcare Commercial |
$15.47
|
| Rate for Payer: United Healthcare Medicare |
$6.28
|
|
|
LINEZOLID IN DEXTROSE 5% 600 MG/300 ML IV PGBK
|
Facility
|
IP
|
$151.20
|
|
|
Service Code
|
HCPCS J2020
|
| Hospital Charge Code |
114051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$113.40 |
| Max. Negotiated Rate |
$140.62 |
| Rate for Payer: Aetna Commercial |
$130.64
|
| Rate for Payer: Cash Price |
$90.72
|
| Rate for Payer: Cigna All Commercial |
$130.49
|
| Rate for Payer: CORVEL All Commercial |
$140.62
|
| Rate for Payer: Coventry All Commercial |
$133.06
|
| Rate for Payer: Encore All Commercial |
$139.18
|
| Rate for Payer: Frontpath All Commercial |
$139.10
|
| Rate for Payer: Humana ChoiceCare |
$130.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$136.08
|
| Rate for Payer: PHCS All Commercial |
$113.40
|
| Rate for Payer: PHP All Commercial |
$114.67
|
| Rate for Payer: Sagamore Health Network All Products |
$116.73
|
| Rate for Payer: Signature Care EPO |
$125.50
|
| Rate for Payer: Signature Care PPO |
$133.06
|
| Rate for Payer: United Healthcare Commercial |
$119.15
|
|
|
LINEZOLID IN DEXTROSE 5% 600 MG/300 ML IV PGBK
|
Facility
|
OP
|
$151.20
|
|
|
Service Code
|
HCPCS J2020
|
| Hospital Charge Code |
114051
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.87 |
| Max. Negotiated Rate |
$140.62 |
| Rate for Payer: Aetna Commercial |
$127.61
|
| Rate for Payer: Aetna Medicare |
$48.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$46.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$86.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$94.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$55.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$53.22
|
| Rate for Payer: Cash Price |
$90.72
|
| Rate for Payer: Centivo All Commercial |
$82.25
|
| Rate for Payer: Cigna All Commercial |
$130.49
|
| Rate for Payer: CORVEL All Commercial |
$140.62
|
| Rate for Payer: Coventry All Commercial |
$133.06
|
| Rate for Payer: Encore All Commercial |
$139.18
|
| Rate for Payer: Frontpath All Commercial |
$139.10
|
| Rate for Payer: Humana ChoiceCare |
$130.59
|
| Rate for Payer: Humana Medicare |
$48.38
|
| Rate for Payer: Lucent All Commercial |
$82.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$136.08
|
| Rate for Payer: PHCS All Commercial |
$113.40
|
| Rate for Payer: PHP All Commercial |
$114.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$58.97
|
| Rate for Payer: Sagamore Health Network All Products |
$116.73
|
| Rate for Payer: Signature Care EPO |
$125.50
|
| Rate for Payer: Signature Care PPO |
$133.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$128.52
|
| Rate for Payer: United Healthcare Commercial |
$119.15
|
| Rate for Payer: United Healthcare Medicare |
$48.38
|
|
|
LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBQ PNIJ
|
Facility
|
OP
|
$1,087.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
100803
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$336.98 |
| Max. Negotiated Rate |
$1,010.93 |
| Rate for Payer: Aetna Commercial |
$917.44
|
| Rate for Payer: Aetna Medicare |
$347.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$336.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$624.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$679.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$400.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$382.63
|
| Rate for Payer: Cash Price |
$652.21
|
| Rate for Payer: Centivo All Commercial |
$591.34
|
| Rate for Payer: Cigna All Commercial |
$938.10
|
| Rate for Payer: CORVEL All Commercial |
$1,010.93
|
| Rate for Payer: Coventry All Commercial |
$956.58
|
| Rate for Payer: Encore All Commercial |
$1,000.60
|
| Rate for Payer: Frontpath All Commercial |
$1,000.06
|
| Rate for Payer: Humana ChoiceCare |
$938.86
|
| Rate for Payer: Humana Medicare |
$347.85
|
| Rate for Payer: Lucent All Commercial |
$591.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$978.32
|
| Rate for Payer: PHCS All Commercial |
$815.26
|
| Rate for Payer: PHP All Commercial |
$824.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$423.94
|
| Rate for Payer: Sagamore Health Network All Products |
$839.18
|
| Rate for Payer: Signature Care EPO |
$902.23
|
| Rate for Payer: Signature Care PPO |
$956.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$923.97
|
| Rate for Payer: United Healthcare Commercial |
$856.57
|
| Rate for Payer: United Healthcare Medicare |
$347.85
|
|
|
LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBQ PNIJ
|
Facility
|
IP
|
$1,087.02
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
100803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$815.26 |
| Max. Negotiated Rate |
$1,010.93 |
| Rate for Payer: Aetna Commercial |
$939.19
|
| Rate for Payer: Cash Price |
$652.21
|
| Rate for Payer: Cigna All Commercial |
$938.10
|
| Rate for Payer: CORVEL All Commercial |
$1,010.93
|
| Rate for Payer: Coventry All Commercial |
$956.58
|
| Rate for Payer: Encore All Commercial |
$1,000.60
|
| Rate for Payer: Frontpath All Commercial |
$1,000.06
|
| Rate for Payer: Humana ChoiceCare |
$938.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$978.32
|
| Rate for Payer: PHCS All Commercial |
$815.26
|
| Rate for Payer: PHP All Commercial |
$824.40
|
| Rate for Payer: Sagamore Health Network All Products |
$839.18
|
| Rate for Payer: Signature Care EPO |
$902.23
|
| Rate for Payer: Signature Care PPO |
$956.58
|
| Rate for Payer: United Healthcare Commercial |
$856.57
|
|
|
LISINOPRIL 10 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904679861
|
| Hospital Charge Code |
10449
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
LISINOPRIL 10 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904679861
|
| Hospital Charge Code |
10449
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
LISINOPRIL 20 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687033301
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
LISINOPRIL 20 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687033301
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
LISINOPRIL 5 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904679761
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
LISINOPRIL 5 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904679761
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
LITHIUM CARBONATE 150 MG ORAL CAP
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 00054852625
|
| Hospital Charge Code |
4528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna Commercial |
$1.03
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna All Commercial |
$1.03
|
| Rate for Payer: CORVEL All Commercial |
$1.11
|
| Rate for Payer: Coventry All Commercial |
$1.05
|
| Rate for Payer: Encore All Commercial |
$1.10
|
| Rate for Payer: Frontpath All Commercial |
$1.09
|
| Rate for Payer: Humana ChoiceCare |
$1.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.07
|
| Rate for Payer: PHCS All Commercial |
$0.89
|
| Rate for Payer: PHP All Commercial |
$0.90
|
| Rate for Payer: Sagamore Health Network All Products |
$0.92
|
| Rate for Payer: Signature Care EPO |
$0.99
|
| Rate for Payer: Signature Care PPO |
$1.05
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
|
|
LITHIUM CARBONATE 150 MG ORAL CAP
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 00054852625
|
| Hospital Charge Code |
4528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna Commercial |
$1.00
|
| Rate for Payer: Aetna Medicare |
$0.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.42
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Centivo All Commercial |
$0.65
|
| Rate for Payer: Cigna All Commercial |
$1.03
|
| Rate for Payer: CORVEL All Commercial |
$1.11
|
| Rate for Payer: Coventry All Commercial |
$1.05
|
| Rate for Payer: Encore All Commercial |
$1.10
|
| Rate for Payer: Frontpath All Commercial |
$1.09
|
| Rate for Payer: Humana ChoiceCare |
$1.03
|
| Rate for Payer: Humana Medicare |
$0.38
|
| Rate for Payer: Lucent All Commercial |
$0.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.07
|
| Rate for Payer: PHCS All Commercial |
$0.89
|
| Rate for Payer: PHP All Commercial |
$0.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.46
|
| Rate for Payer: Sagamore Health Network All Products |
$0.92
|
| Rate for Payer: Signature Care EPO |
$0.99
|
| Rate for Payer: Signature Care PPO |
$1.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.01
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
| Rate for Payer: United Healthcare Medicare |
$0.38
|
|
|
LOPERAMIDE 2 MG ORAL CAP
|
Facility
|
IP
|
$5.21
|
|
|
Service Code
|
NDC 51079069001
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.91 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cigna All Commercial |
$4.49
|
| Rate for Payer: CORVEL All Commercial |
$4.84
|
| Rate for Payer: Coventry All Commercial |
$4.58
|
| Rate for Payer: Encore All Commercial |
$4.79
|
| Rate for Payer: Frontpath All Commercial |
$4.79
|
| Rate for Payer: Humana ChoiceCare |
$4.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.69
|
| Rate for Payer: PHCS All Commercial |
$3.91
|
| Rate for Payer: PHP All Commercial |
$3.95
|
| Rate for Payer: Sagamore Health Network All Products |
$4.02
|
| Rate for Payer: Signature Care EPO |
$4.32
|
| Rate for Payer: Signature Care PPO |
$4.58
|
| Rate for Payer: United Healthcare Commercial |
$4.10
|
|
