|
LOPERAMIDE 2 MG ORAL CAP
|
Facility
|
OP
|
$5.21
|
|
|
Service Code
|
NDC 51079069001
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna Commercial |
$4.40
|
| Rate for Payer: Aetna Medicare |
$1.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.83
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Centivo All Commercial |
$2.83
|
| 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: Humana Medicare |
$1.67
|
| Rate for Payer: Lucent All Commercial |
$2.83
|
| 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: Plain Church Group Ministry All Commercial |
$2.03
|
| 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: Three Rivers Preferred All Commercial |
$4.43
|
| Rate for Payer: United Healthcare Commercial |
$4.10
|
| Rate for Payer: United Healthcare Medicare |
$1.67
|
|
|
LORAZEPAM 0.5 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 69315090401
|
| Hospital Charge Code |
4572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
LORAZEPAM 0.5 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 69315090401
|
| Hospital Charge Code |
4572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
LORAZEPAM 1 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 69315090501
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
LORAZEPAM 1 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 69315090501
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
LORAZEPAM 2 MG/ML INJECTION S.O.
|
Facility
|
OP
|
$61.04
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
408010467
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.92 |
| Max. Negotiated Rate |
$56.77 |
| Rate for Payer: Aetna Commercial |
$51.52
|
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Aetna Medicare |
$19.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$35.06
|
| 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 |
$38.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$22.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$21.49
|
| Rate for Payer: Cash Price |
$36.62
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$33.21
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$52.68
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$56.77
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Coventry All Commercial |
$53.72
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Encore All Commercial |
$56.19
|
| Rate for Payer: Frontpath All Commercial |
$56.16
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$52.72
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$19.53
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lucent All Commercial |
$33.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$54.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$45.78
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$46.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.81
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Sagamore Health Network All Products |
$47.12
|
| Rate for Payer: Signature Care EPO |
$50.66
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$53.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$51.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$48.10
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
| Rate for Payer: United Healthcare Medicare |
$19.53
|
|
|
LORAZEPAM 2 MG/ML INJECTION S.O.
|
Facility
|
IP
|
$61.04
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
408010467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.78 |
| Max. Negotiated Rate |
$56.77 |
| Rate for Payer: Aetna Commercial |
$52.74
|
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$36.62
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$52.68
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$56.77
|
| Rate for Payer: Coventry All Commercial |
$53.72
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$56.19
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Frontpath All Commercial |
$56.16
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana ChoiceCare |
$52.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$54.94
|
| Rate for Payer: PHCS All Commercial |
$45.78
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$46.29
|
| Rate for Payer: Sagamore Health Network All Products |
$47.12
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$50.66
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$53.72
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$48.10
|
|
|
LORAZEPAM 2 MG/ML INJ SOLN
|
Facility
|
IP
|
$61.04
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
10467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.78 |
| Max. Negotiated Rate |
$56.77 |
| Rate for Payer: Aetna Commercial |
$52.74
|
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$36.62
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$52.68
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$56.77
|
| Rate for Payer: Coventry All Commercial |
$53.72
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$56.19
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Frontpath All Commercial |
$56.16
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana ChoiceCare |
$52.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$54.94
|
| Rate for Payer: PHCS All Commercial |
$45.78
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$46.29
|
| Rate for Payer: Sagamore Health Network All Products |
$47.12
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$50.66
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$53.72
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$48.10
|
|
|
LORAZEPAM 2 MG/ML INJ SOLN
|
Facility
|
OP
|
$61.04
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
10467
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.92 |
| Max. Negotiated Rate |
$56.77 |
| Rate for Payer: Aetna Commercial |
$51.52
|
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Aetna Medicare |
$19.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$35.06
|
| 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 |
$38.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$22.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$21.49
|
| Rate for Payer: Cash Price |
$36.62
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$33.21
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: Cigna All Commercial |
$52.68
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$56.77
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Coventry All Commercial |
$53.72
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Encore All Commercial |
$56.19
|
| Rate for Payer: Frontpath All Commercial |
$56.16
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$52.72
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$19.53
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lucent All Commercial |
$33.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$54.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$45.78
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$46.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$23.81
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Sagamore Health Network All Products |
$47.12
|
| Rate for Payer: Signature Care EPO |
$50.66
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$53.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$51.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$48.10
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
| Rate for Payer: United Healthcare Medicare |
$19.53
|
|
|
LORAZEPAM 2 MG/ML ORAL CONC
|
Facility
|
IP
|
$4.17
|
|
|
Service Code
|
NDC 00543532
|
| Hospital Charge Code |
4571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cigna All Commercial |
$3.60
|
| Rate for Payer: CORVEL All Commercial |
$3.88
|
| Rate for Payer: Coventry All Commercial |
$3.67
|
| Rate for Payer: Encore All Commercial |
$3.84
|
| Rate for Payer: Frontpath All Commercial |
$3.84
|
| Rate for Payer: Humana ChoiceCare |
$3.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.75
|
| Rate for Payer: PHCS All Commercial |
$3.13
|
| Rate for Payer: PHP All Commercial |
$3.16
|
| Rate for Payer: Sagamore Health Network All Products |
$3.22
|
| Rate for Payer: Signature Care EPO |
$3.46
|
| Rate for Payer: Signature Care PPO |
$3.67
|
| Rate for Payer: United Healthcare Commercial |
$3.29
|
|
|
LORAZEPAM 2 MG/ML ORAL CONC
|
Facility
|
OP
|
$125.16
|
|
|
Service Code
|
NDC 00054353244
|
| Hospital Charge Code |
4571
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.80 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: Aetna Commercial |
$105.64
|
| Rate for Payer: Aetna Medicare |
$40.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$38.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$71.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$78.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$46.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$44.06
|
| Rate for Payer: Cash Price |
$75.10
|
| Rate for Payer: Centivo All Commercial |
$68.09
|
| Rate for Payer: Cigna All Commercial |
$108.01
|
| Rate for Payer: CORVEL All Commercial |
$116.40
|
| Rate for Payer: Coventry All Commercial |
$110.14
|
| Rate for Payer: Encore All Commercial |
$115.21
|
| Rate for Payer: Frontpath All Commercial |
$115.15
|
| Rate for Payer: Humana ChoiceCare |
$108.10
|
| Rate for Payer: Humana Medicare |
$40.05
|
| Rate for Payer: Lucent All Commercial |
$68.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$112.64
|
| Rate for Payer: PHCS All Commercial |
$93.87
|
| Rate for Payer: PHP All Commercial |
$94.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$48.81
|
| Rate for Payer: Sagamore Health Network All Products |
$96.62
|
| Rate for Payer: Signature Care EPO |
$103.88
|
| Rate for Payer: Signature Care PPO |
$110.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$106.39
|
| Rate for Payer: United Healthcare Commercial |
$98.63
|
| Rate for Payer: United Healthcare Medicare |
$40.05
|
|
|
LORAZEPAM 2 MG/ML ORAL CONC
|
Facility
|
OP
|
$4.17
|
|
|
Service Code
|
NDC 00543532
|
| Hospital Charge Code |
4571
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Aetna Medicare |
$1.34
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.61
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.47
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Centivo All Commercial |
$2.27
|
| Rate for Payer: Cigna All Commercial |
$3.60
|
| Rate for Payer: CORVEL All Commercial |
$3.88
|
| Rate for Payer: Coventry All Commercial |
$3.67
|
| Rate for Payer: Encore All Commercial |
$3.84
|
| Rate for Payer: Frontpath All Commercial |
$3.84
|
| Rate for Payer: Humana ChoiceCare |
$3.60
|
| Rate for Payer: Humana Medicare |
$1.34
|
| Rate for Payer: Lucent All Commercial |
$2.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.75
|
| Rate for Payer: PHCS All Commercial |
$3.13
|
| Rate for Payer: PHP All Commercial |
$3.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.63
|
| Rate for Payer: Sagamore Health Network All Products |
$3.22
|
| Rate for Payer: Signature Care EPO |
$3.46
|
| Rate for Payer: Signature Care PPO |
$3.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.55
|
| Rate for Payer: United Healthcare Commercial |
$3.29
|
| Rate for Payer: United Healthcare Medicare |
$1.34
|
|
|
LORAZEPAM 2 MG/ML ORAL CONC
|
Facility
|
IP
|
$125.16
|
|
|
Service Code
|
NDC 00054353244
|
| Hospital Charge Code |
4571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$93.87 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: Aetna Commercial |
$108.14
|
| Rate for Payer: Cash Price |
$75.10
|
| Rate for Payer: Cigna All Commercial |
$108.01
|
| Rate for Payer: CORVEL All Commercial |
$116.40
|
| Rate for Payer: Coventry All Commercial |
$110.14
|
| Rate for Payer: Encore All Commercial |
$115.21
|
| Rate for Payer: Frontpath All Commercial |
$115.15
|
| Rate for Payer: Humana ChoiceCare |
$108.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$112.64
|
| Rate for Payer: PHCS All Commercial |
$93.87
|
| Rate for Payer: PHP All Commercial |
$94.92
|
| Rate for Payer: Sagamore Health Network All Products |
$96.62
|
| Rate for Payer: Signature Care EPO |
$103.88
|
| Rate for Payer: Signature Care PPO |
$110.14
|
| Rate for Payer: United Healthcare Commercial |
$98.63
|
|
|
LORAZEPAM 4 MG/ML INJ SOLN
|
Facility
|
IP
|
$19.58
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
10468
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.68 |
| Max. Negotiated Rate |
$18.21 |
| Rate for Payer: Aetna Commercial |
$16.92
|
| Rate for Payer: Cash Price |
$11.75
|
| Rate for Payer: Cigna All Commercial |
$16.90
|
| Rate for Payer: CORVEL All Commercial |
$18.21
|
| Rate for Payer: Coventry All Commercial |
$17.23
|
| Rate for Payer: Encore All Commercial |
$18.02
|
| Rate for Payer: Frontpath All Commercial |
$18.01
|
| Rate for Payer: Humana ChoiceCare |
$16.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.62
|
| Rate for Payer: PHCS All Commercial |
$14.68
|
| Rate for Payer: PHP All Commercial |
$14.85
|
| Rate for Payer: Sagamore Health Network All Products |
$15.11
|
| Rate for Payer: Signature Care EPO |
$16.25
|
| Rate for Payer: Signature Care PPO |
$17.23
|
| Rate for Payer: United Healthcare Commercial |
$15.43
|
|
|
LORAZEPAM 4 MG/ML INJ SOLN
|
Facility
|
OP
|
$19.58
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
10468
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$18.21 |
| Rate for Payer: Aetna Commercial |
$16.52
|
| Rate for Payer: Aetna Medicare |
$6.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.89
|
| Rate for Payer: Cash Price |
$11.75
|
| Rate for Payer: Centivo All Commercial |
$10.65
|
| Rate for Payer: Cigna All Commercial |
$16.90
|
| Rate for Payer: CORVEL All Commercial |
$18.21
|
| Rate for Payer: Coventry All Commercial |
$17.23
|
| Rate for Payer: Encore All Commercial |
$18.02
|
| Rate for Payer: Frontpath All Commercial |
$18.01
|
| Rate for Payer: Humana ChoiceCare |
$16.91
|
| Rate for Payer: Humana Medicare |
$6.27
|
| Rate for Payer: Lucent All Commercial |
$10.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.62
|
| Rate for Payer: PHCS All Commercial |
$14.68
|
| Rate for Payer: PHP All Commercial |
$14.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.64
|
| Rate for Payer: Sagamore Health Network All Products |
$15.11
|
| Rate for Payer: Signature Care EPO |
$16.25
|
| Rate for Payer: Signature Care PPO |
$17.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.64
|
| Rate for Payer: United Healthcare Commercial |
$15.43
|
| Rate for Payer: United Healthcare Medicare |
$6.27
|
|
|
LOSARTAN 50 MG ORAL TAB
|
Facility
|
IP
|
$1.77
|
|
|
Service Code
|
NDC 68084034701
|
| Hospital Charge Code |
14824
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Cigna All Commercial |
$1.53
|
| Rate for Payer: CORVEL All Commercial |
$1.65
|
| Rate for Payer: Coventry All Commercial |
$1.56
|
| Rate for Payer: Encore All Commercial |
$1.63
|
| Rate for Payer: Frontpath All Commercial |
$1.63
|
| Rate for Payer: Humana ChoiceCare |
$1.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.59
|
| Rate for Payer: PHCS All Commercial |
$1.33
|
| Rate for Payer: PHP All Commercial |
$1.34
|
| Rate for Payer: Sagamore Health Network All Products |
$1.37
|
| Rate for Payer: Signature Care EPO |
$1.47
|
| Rate for Payer: Signature Care PPO |
$1.56
|
| Rate for Payer: United Healthcare Commercial |
$1.40
|
|
|
LOSARTAN 50 MG ORAL TAB
|
Facility
|
OP
|
$1.77
|
|
|
Service Code
|
NDC 68084034701
|
| Hospital Charge Code |
14824
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna Commercial |
$1.49
|
| Rate for Payer: Aetna Medicare |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.11
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.06
|
| Rate for Payer: Centivo All Commercial |
$0.96
|
| Rate for Payer: Cigna All Commercial |
$1.53
|
| Rate for Payer: CORVEL All Commercial |
$1.65
|
| Rate for Payer: Coventry All Commercial |
$1.56
|
| Rate for Payer: Encore All Commercial |
$1.63
|
| Rate for Payer: Frontpath All Commercial |
$1.63
|
| Rate for Payer: Humana ChoiceCare |
$1.53
|
| Rate for Payer: Humana Medicare |
$0.57
|
| Rate for Payer: Lucent All Commercial |
$0.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.59
|
| Rate for Payer: PHCS All Commercial |
$1.33
|
| Rate for Payer: PHP All Commercial |
$1.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.69
|
| Rate for Payer: Sagamore Health Network All Products |
$1.37
|
| Rate for Payer: Signature Care EPO |
$1.47
|
| Rate for Payer: Signature Care PPO |
$1.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.51
|
| Rate for Payer: United Healthcare Commercial |
$1.40
|
| Rate for Payer: United Healthcare Medicare |
$0.57
|
|
|
LUBIPROSTONE 8 MCG ORAL CAP
|
Facility
|
IP
|
$41.07
|
|
|
Service Code
|
NDC 64764008060
|
| Hospital Charge Code |
91534
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$38.19 |
| Rate for Payer: Aetna Commercial |
$35.48
|
| Rate for Payer: Cash Price |
$24.64
|
| Rate for Payer: Cigna All Commercial |
$35.44
|
| Rate for Payer: CORVEL All Commercial |
$38.19
|
| Rate for Payer: Coventry All Commercial |
$36.14
|
| Rate for Payer: Encore All Commercial |
$37.80
|
| Rate for Payer: Frontpath All Commercial |
$37.78
|
| Rate for Payer: Humana ChoiceCare |
$35.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$36.96
|
| Rate for Payer: PHCS All Commercial |
$30.80
|
| Rate for Payer: PHP All Commercial |
$31.15
|
| Rate for Payer: Sagamore Health Network All Products |
$31.71
|
| Rate for Payer: Signature Care EPO |
$34.09
|
| Rate for Payer: Signature Care PPO |
$36.14
|
| Rate for Payer: United Healthcare Commercial |
$32.36
|
|
|
LUBIPROSTONE 8 MCG ORAL CAP
|
Facility
|
OP
|
$41.07
|
|
|
Service Code
|
NDC 64764008060
|
| Hospital Charge Code |
91534
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.73 |
| Max. Negotiated Rate |
$38.19 |
| Rate for Payer: Aetna Commercial |
$34.66
|
| Rate for Payer: Aetna Medicare |
$13.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$23.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$25.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.46
|
| Rate for Payer: Cash Price |
$24.64
|
| Rate for Payer: Centivo All Commercial |
$22.34
|
| Rate for Payer: Cigna All Commercial |
$35.44
|
| Rate for Payer: CORVEL All Commercial |
$38.19
|
| Rate for Payer: Coventry All Commercial |
$36.14
|
| Rate for Payer: Encore All Commercial |
$37.80
|
| Rate for Payer: Frontpath All Commercial |
$37.78
|
| Rate for Payer: Humana ChoiceCare |
$35.47
|
| Rate for Payer: Humana Medicare |
$13.14
|
| Rate for Payer: Lucent All Commercial |
$22.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$36.96
|
| Rate for Payer: PHCS All Commercial |
$30.80
|
| Rate for Payer: PHP All Commercial |
$31.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.02
|
| Rate for Payer: Sagamore Health Network All Products |
$31.71
|
| Rate for Payer: Signature Care EPO |
$34.09
|
| Rate for Payer: Signature Care PPO |
$36.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$34.91
|
| Rate for Payer: United Healthcare Commercial |
$32.36
|
| Rate for Payer: United Healthcare Medicare |
$13.14
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$11.13
|
|
|
Service Code
|
NDC 00121043130
|
| Hospital Charge Code |
111171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$10.35 |
| Rate for Payer: Aetna Commercial |
$9.39
|
| Rate for Payer: Aetna Medicare |
$3.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.96
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.92
|
| Rate for Payer: Cash Price |
$6.68
|
| Rate for Payer: Cash Price |
$6.68
|
| Rate for Payer: Centivo All Commercial |
$6.05
|
| Rate for Payer: Cigna All Commercial |
$9.61
|
| Rate for Payer: CORVEL All Commercial |
$10.35
|
| Rate for Payer: Coventry All Commercial |
$9.79
|
| Rate for Payer: Encore All Commercial |
$10.25
|
| Rate for Payer: Frontpath All Commercial |
$10.24
|
| Rate for Payer: Humana ChoiceCare |
$9.61
|
| Rate for Payer: Humana Medicare |
$3.56
|
| Rate for Payer: Lucent All Commercial |
$6.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.02
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$8.35
|
| Rate for Payer: PHP All Commercial |
$8.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.34
|
| Rate for Payer: Sagamore Health Network All Products |
$8.59
|
| Rate for Payer: Signature Care EPO |
$9.24
|
| Rate for Payer: Signature Care PPO |
$9.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9.46
|
| Rate for Payer: United Healthcare Commercial |
$8.77
|
| Rate for Payer: United Healthcare Medicare |
$3.56
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$11.13
|
|
|
Service Code
|
NDC 00121043130
|
| Hospital Charge Code |
111171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.35 |
| Max. Negotiated Rate |
$10.35 |
| Rate for Payer: Aetna Commercial |
$9.62
|
| Rate for Payer: Cash Price |
$6.68
|
| Rate for Payer: Cigna All Commercial |
$9.61
|
| Rate for Payer: CORVEL All Commercial |
$10.35
|
| Rate for Payer: Coventry All Commercial |
$9.79
|
| Rate for Payer: Encore All Commercial |
$10.25
|
| Rate for Payer: Frontpath All Commercial |
$10.24
|
| Rate for Payer: Humana ChoiceCare |
$9.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.02
|
| Rate for Payer: PHCS All Commercial |
$8.35
|
| Rate for Payer: PHP All Commercial |
$8.44
|
| Rate for Payer: Sagamore Health Network All Products |
$8.59
|
| Rate for Payer: Signature Care EPO |
$9.24
|
| Rate for Payer: Signature Care PPO |
$9.79
|
| Rate for Payer: United Healthcare Commercial |
$8.77
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) ORAL TAB
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 64980033901
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Aetna Commercial |
$0.58
|
| Rate for Payer: Aetna Medicare |
$0.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.43
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.24
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Centivo All Commercial |
$0.37
|
| Rate for Payer: Cigna All Commercial |
$0.59
|
| Rate for Payer: CORVEL All Commercial |
$0.64
|
| Rate for Payer: Coventry All Commercial |
$0.60
|
| Rate for Payer: Encore All Commercial |
$0.63
|
| Rate for Payer: Frontpath All Commercial |
$0.63
|
| Rate for Payer: Humana ChoiceCare |
$0.59
|
| Rate for Payer: Humana Medicare |
$0.22
|
| Rate for Payer: Lucent All Commercial |
$0.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.62
|
| Rate for Payer: PHCS All Commercial |
$0.51
|
| Rate for Payer: PHP All Commercial |
$0.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.27
|
| Rate for Payer: Sagamore Health Network All Products |
$0.53
|
| Rate for Payer: Signature Care EPO |
$0.57
|
| Rate for Payer: Signature Care PPO |
$0.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.58
|
| Rate for Payer: United Healthcare Commercial |
$0.54
|
| Rate for Payer: United Healthcare Medicare |
$0.22
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) ORAL TAB
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 64980033901
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Aetna Commercial |
$0.59
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna All Commercial |
$0.59
|
| Rate for Payer: CORVEL All Commercial |
$0.64
|
| Rate for Payer: Coventry All Commercial |
$0.60
|
| Rate for Payer: Encore All Commercial |
$0.63
|
| Rate for Payer: Frontpath All Commercial |
$0.63
|
| Rate for Payer: Humana ChoiceCare |
$0.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.62
|
| Rate for Payer: PHCS All Commercial |
$0.51
|
| Rate for Payer: PHP All Commercial |
$0.52
|
| Rate for Payer: Sagamore Health Network All Products |
$0.53
|
| Rate for Payer: Signature Care EPO |
$0.57
|
| Rate for Payer: Signature Care PPO |
$0.60
|
| Rate for Payer: United Healthcare Commercial |
$0.54
|
|
|
MAGNESIUM SULFATE 1 GRAM/100 ML IVPB
|
Facility
|
OP
|
$30.80
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
16162
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.55 |
| Max. Negotiated Rate |
$28.64 |
| Rate for Payer: Aetna Commercial |
$26.00
|
| Rate for Payer: Aetna Medicare |
$9.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$17.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.84
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Centivo All Commercial |
$16.76
|
| Rate for Payer: Cigna All Commercial |
$26.58
|
| Rate for Payer: CORVEL All Commercial |
$28.64
|
| Rate for Payer: Coventry All Commercial |
$27.10
|
| Rate for Payer: Encore All Commercial |
$28.35
|
| Rate for Payer: Frontpath All Commercial |
$28.34
|
| Rate for Payer: Humana ChoiceCare |
$26.60
|
| Rate for Payer: Humana Medicare |
$9.86
|
| Rate for Payer: Lucent All Commercial |
$16.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.72
|
| Rate for Payer: PHCS All Commercial |
$23.10
|
| Rate for Payer: PHP All Commercial |
$23.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.01
|
| Rate for Payer: Sagamore Health Network All Products |
$23.78
|
| Rate for Payer: Signature Care EPO |
$25.56
|
| Rate for Payer: Signature Care PPO |
$27.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.18
|
| Rate for Payer: United Healthcare Commercial |
$24.27
|
| Rate for Payer: United Healthcare Medicare |
$9.86
|
|
|
MAGNESIUM SULFATE 1 GRAM/100 ML IVPB
|
Facility
|
IP
|
$30.80
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
16162
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$28.64 |
| Rate for Payer: Aetna Commercial |
$26.61
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cigna All Commercial |
$26.58
|
| Rate for Payer: CORVEL All Commercial |
$28.64
|
| Rate for Payer: Coventry All Commercial |
$27.10
|
| Rate for Payer: Encore All Commercial |
$28.35
|
| Rate for Payer: Frontpath All Commercial |
$28.34
|
| Rate for Payer: Humana ChoiceCare |
$26.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.72
|
| Rate for Payer: PHCS All Commercial |
$23.10
|
| Rate for Payer: PHP All Commercial |
$23.36
|
| Rate for Payer: Sagamore Health Network All Products |
$23.78
|
| Rate for Payer: Signature Care EPO |
$25.56
|
| Rate for Payer: Signature Care PPO |
$27.10
|
| Rate for Payer: United Healthcare Commercial |
$24.27
|
|
