|
KIT PREP TC 99M-PENTETIC ACID 20 MG IV SOLR
|
Facility
OP
|
$387.42
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
152912
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$127.85 |
| Max. Negotiated Rate |
$360.30 |
| Rate for Payer: Aetna Commercial |
$326.98
|
| Rate for Payer: Aetna Medicare |
$127.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$127.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$222.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$242.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$147.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$140.63
|
| Rate for Payer: Cash Price |
$240.20
|
| Rate for Payer: Centivo All Commercial |
$197.58
|
| Rate for Payer: Cigna All Commercial |
$334.34
|
| Rate for Payer: CORVEL All Commercial |
$360.30
|
| Rate for Payer: Coventry All Commercial |
$340.93
|
| Rate for Payer: Encore All Commercial |
$356.62
|
| Rate for Payer: Frontpath All Commercial |
$356.43
|
| Rate for Payer: Humana ChoiceCare |
$334.61
|
| Rate for Payer: Humana Medicare |
$197.58
|
| Rate for Payer: Lucent All Commercial |
$197.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$348.68
|
| Rate for Payer: PHCS All Commercial |
$290.56
|
| Rate for Payer: PHP All Commercial |
$293.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$151.09
|
| Rate for Payer: Sagamore Health Network All Products |
$299.09
|
| Rate for Payer: Signature Care EPO |
$321.56
|
| Rate for Payer: Signature Care PPO |
$340.93
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$329.31
|
| Rate for Payer: United Healthcare Commercial |
$305.29
|
| Rate for Payer: United Healthcare Medicare |
$127.85
|
|
|
LABETALOL 200 MG ORAL TAB
|
Facility
IP
|
$2.22
|
|
|
Service Code
|
NDC 00904711061
|
| Hospital Charge Code |
10374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Aetna Commercial |
$1.92
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Cigna All Commercial |
$1.91
|
| Rate for Payer: CORVEL All Commercial |
$2.06
|
| Rate for Payer: Coventry All Commercial |
$1.95
|
| Rate for Payer: Encore All Commercial |
$2.04
|
| Rate for Payer: Frontpath All Commercial |
$2.04
|
| Rate for Payer: Humana ChoiceCare |
$1.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.00
|
| Rate for Payer: PHCS All Commercial |
$1.66
|
| Rate for Payer: PHP All Commercial |
$1.68
|
| Rate for Payer: Sagamore Health Network All Products |
$1.71
|
| Rate for Payer: Signature Care EPO |
$1.84
|
| Rate for Payer: Signature Care PPO |
$1.95
|
| Rate for Payer: United Healthcare Commercial |
$1.75
|
|
|
LABETALOL 200 MG ORAL TAB
|
Facility
OP
|
$2.22
|
|
|
Service Code
|
NDC 00904711061
|
| Hospital Charge Code |
10374
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Aetna Commercial |
$1.87
|
| Rate for Payer: Aetna Medicare |
$0.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.39
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.81
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: Centivo All Commercial |
$1.13
|
| Rate for Payer: Cigna All Commercial |
$1.91
|
| Rate for Payer: CORVEL All Commercial |
$2.06
|
| Rate for Payer: Coventry All Commercial |
$1.95
|
| Rate for Payer: Encore All Commercial |
$2.04
|
| Rate for Payer: Frontpath All Commercial |
$2.04
|
| Rate for Payer: Humana ChoiceCare |
$1.92
|
| Rate for Payer: Humana Medicare |
$1.13
|
| Rate for Payer: Lucent All Commercial |
$1.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.00
|
| Rate for Payer: PHCS All Commercial |
$1.66
|
| Rate for Payer: PHP All Commercial |
$1.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.87
|
| Rate for Payer: Sagamore Health Network All Products |
$1.71
|
| Rate for Payer: Signature Care EPO |
$1.84
|
| Rate for Payer: Signature Care PPO |
$1.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.89
|
| Rate for Payer: United Healthcare Commercial |
$1.75
|
| Rate for Payer: United Healthcare Medicare |
$0.73
|
|
|
LABETALOL 20 MG/4 ML (5 MG/ML) IV SYRG
|
Facility
OP
|
$54.24
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
153505
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.90 |
| Max. Negotiated Rate |
$50.44 |
| Rate for Payer: Aetna Commercial |
$45.78
|
| Rate for Payer: Aetna Medicare |
$17.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$31.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$33.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$20.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.69
|
| Rate for Payer: Cash Price |
$33.63
|
| Rate for Payer: Centivo All Commercial |
$27.66
|
| Rate for Payer: Cigna All Commercial |
$46.81
|
| Rate for Payer: CORVEL All Commercial |
$50.44
|
| Rate for Payer: Coventry All Commercial |
$47.73
|
| Rate for Payer: Encore All Commercial |
$49.92
|
| Rate for Payer: Frontpath All Commercial |
$49.90
|
| Rate for Payer: Humana ChoiceCare |
$46.84
|
| Rate for Payer: Humana Medicare |
$27.66
|
| Rate for Payer: Lucent All Commercial |
$27.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.81
|
| Rate for Payer: PHCS All Commercial |
$40.68
|
| Rate for Payer: PHP All Commercial |
$41.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$21.15
|
| Rate for Payer: Sagamore Health Network All Products |
$41.87
|
| Rate for Payer: Signature Care EPO |
$45.02
|
| Rate for Payer: Signature Care PPO |
$47.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$46.10
|
| Rate for Payer: United Healthcare Commercial |
$42.74
|
| Rate for Payer: United Healthcare Medicare |
$17.90
|
|
|
LABETALOL 20 MG/4 ML (5 MG/ML) IV SYRG
|
Facility
IP
|
$54.24
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
153505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.68 |
| Max. Negotiated Rate |
$50.44 |
| Rate for Payer: Aetna Commercial |
$46.86
|
| Rate for Payer: Cash Price |
$33.63
|
| Rate for Payer: Cigna All Commercial |
$46.81
|
| Rate for Payer: CORVEL All Commercial |
$50.44
|
| Rate for Payer: Coventry All Commercial |
$47.73
|
| Rate for Payer: Encore All Commercial |
$49.92
|
| Rate for Payer: Frontpath All Commercial |
$49.90
|
| Rate for Payer: Humana ChoiceCare |
$46.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.81
|
| Rate for Payer: PHCS All Commercial |
$40.68
|
| Rate for Payer: PHP All Commercial |
$41.13
|
| Rate for Payer: Sagamore Health Network All Products |
$41.87
|
| Rate for Payer: Signature Care EPO |
$45.02
|
| Rate for Payer: Signature Care PPO |
$47.73
|
| Rate for Payer: United Healthcare Commercial |
$42.74
|
|
|
LABETALOL 5 MG/ML IV SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
10372
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Commercial |
$41.12
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Aetna Medicare |
$16.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$27.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.49
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.69
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Centivo All Commercial |
$24.85
|
| Rate for Payer: Cigna All Commercial |
$42.05
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: CORVEL All Commercial |
$45.31
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Coventry All Commercial |
$42.87
|
| Rate for Payer: Encore All Commercial |
$44.85
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Frontpath All Commercial |
$44.82
|
| Rate for Payer: Humana ChoiceCare |
$42.08
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$24.85
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$24.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHCS All Commercial |
$36.54
|
| Rate for Payer: PHP All Commercial |
$36.95
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Sagamore Health Network All Products |
$37.61
|
| Rate for Payer: Signature Care EPO |
$40.44
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Signature Care PPO |
$42.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.41
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$38.39
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
| Rate for Payer: United Healthcare Medicare |
$16.08
|
|
|
LABETALOL 5 MG/ML IV SOLN
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
10372
|
|
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 |
$42.09
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cigna All Commercial |
$42.05
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$45.31
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Coventry All Commercial |
$42.87
|
| Rate for Payer: Encore All Commercial |
$44.85
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$44.82
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana ChoiceCare |
$42.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$36.54
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: PHP All Commercial |
$36.95
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Sagamore Health Network All Products |
$37.61
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care EPO |
$40.44
|
| Rate for Payer: Signature Care PPO |
$42.87
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Commercial |
$38.39
|
|
|
LACOSAMIDE 50 MG ORAL TAB
|
Facility
IP
|
$5.11
|
|
|
Service Code
|
NDC 00904724468
|
| Hospital Charge Code |
96968
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.83 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.42
|
| Rate for Payer: Cash Price |
$3.17
|
| Rate for Payer: Cigna All Commercial |
$4.41
|
| Rate for Payer: CORVEL All Commercial |
$4.75
|
| Rate for Payer: Coventry All Commercial |
$4.50
|
| Rate for Payer: Encore All Commercial |
$4.70
|
| Rate for Payer: Frontpath All Commercial |
$4.70
|
| Rate for Payer: Humana ChoiceCare |
$4.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.60
|
| Rate for Payer: PHCS All Commercial |
$3.83
|
| Rate for Payer: PHP All Commercial |
$3.88
|
| Rate for Payer: Sagamore Health Network All Products |
$3.94
|
| Rate for Payer: Signature Care EPO |
$4.24
|
| Rate for Payer: Signature Care PPO |
$4.50
|
| Rate for Payer: United Healthcare Commercial |
$4.03
|
|
|
LACOSAMIDE 50 MG ORAL TAB
|
Facility
OP
|
$5.11
|
|
|
Service Code
|
NDC 00904724468
|
| Hospital Charge Code |
96968
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.31
|
| Rate for Payer: Aetna Medicare |
$1.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.85
|
| Rate for Payer: Cash Price |
$3.17
|
| Rate for Payer: Centivo All Commercial |
$2.61
|
| Rate for Payer: Cigna All Commercial |
$4.41
|
| Rate for Payer: CORVEL All Commercial |
$4.75
|
| Rate for Payer: Coventry All Commercial |
$4.50
|
| Rate for Payer: Encore All Commercial |
$4.70
|
| Rate for Payer: Frontpath All Commercial |
$4.70
|
| Rate for Payer: Humana ChoiceCare |
$4.41
|
| Rate for Payer: Humana Medicare |
$2.61
|
| Rate for Payer: Lucent All Commercial |
$2.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.60
|
| Rate for Payer: PHCS All Commercial |
$3.83
|
| Rate for Payer: PHP All Commercial |
$3.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.99
|
| Rate for Payer: Sagamore Health Network All Products |
$3.94
|
| Rate for Payer: Signature Care EPO |
$4.24
|
| Rate for Payer: Signature Care PPO |
$4.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.34
|
| Rate for Payer: United Healthcare Commercial |
$4.03
|
| Rate for Payer: United Healthcare Medicare |
$1.69
|
|
|
LACTATED RINGERS IRRIGATION SOLP
|
Facility
OP
|
$35.00
|
|
|
Service Code
|
NDC 00338011704
|
| Hospital Charge Code |
1404318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$29.54
|
| Rate for Payer: Aetna Medicare |
$11.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.70
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Centivo All Commercial |
$17.85
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Humana Medicare |
$17.85
|
| Rate for Payer: Lucent All Commercial |
$17.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.75
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
| Rate for Payer: United Healthcare Medicare |
$11.55
|
|
|
LACTATED RINGERS IRRIGATION SOLP
|
Facility
IP
|
$35.00
|
|
|
Service Code
|
NDC 00338011704
|
| Hospital Charge Code |
1404318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$30.24
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
|
|
LACTATED RINGERS IV SOLP
|
Facility
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
4318
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$30.24
|
| Rate for Payer: Aetna Commercial |
$27.22
|
| Rate for Payer: Cash Price |
$19.53
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Cigna All Commercial |
$27.18
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: CORVEL All Commercial |
$29.30
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Coventry All Commercial |
$27.72
|
| Rate for Payer: Encore All Commercial |
$29.00
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$28.98
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Humana ChoiceCare |
$27.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: PHCS All Commercial |
$23.62
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: PHP All Commercial |
$23.89
|
| Rate for Payer: Sagamore Health Network All Products |
$24.32
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$26.14
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: Signature Care PPO |
$27.72
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
|
|
LACTATED RINGERS IV SOLP
|
Facility
OP
|
$31.50
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
4318
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna Commercial |
$26.59
|
| Rate for Payer: Aetna Commercial |
$29.54
|
| Rate for Payer: Aetna Medicare |
$10.40
|
| Rate for Payer: Aetna Medicare |
$11.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$18.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.43
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Cash Price |
$19.53
|
| Rate for Payer: Centivo All Commercial |
$16.06
|
| Rate for Payer: Centivo All Commercial |
$17.85
|
| Rate for Payer: Cigna All Commercial |
$27.18
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: CORVEL All Commercial |
$29.30
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Coventry All Commercial |
$27.72
|
| Rate for Payer: Encore All Commercial |
$29.00
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Frontpath All Commercial |
$28.98
|
| Rate for Payer: Humana ChoiceCare |
$27.21
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Humana Medicare |
$16.06
|
| Rate for Payer: Humana Medicare |
$17.85
|
| Rate for Payer: Lucent All Commercial |
$17.85
|
| Rate for Payer: Lucent All Commercial |
$16.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: PHCS All Commercial |
$23.62
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: PHP All Commercial |
$23.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$24.32
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care EPO |
$26.14
|
| Rate for Payer: Signature Care PPO |
$27.72
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.78
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
| Rate for Payer: United Healthcare Medicare |
$10.40
|
| Rate for Payer: United Healthcare Medicare |
$11.55
|
|
|
LACTOBACILLUS RHAMNOSUS GG 15 BILLION CELLS ORAL CPSP
|
Facility
IP
|
$3.98
|
|
|
Service Code
|
NDC 49100036374
|
| Hospital Charge Code |
164424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Cigna All Commercial |
$3.43
|
| Rate for Payer: CORVEL All Commercial |
$3.70
|
| Rate for Payer: Coventry All Commercial |
$3.50
|
| Rate for Payer: Encore All Commercial |
$3.66
|
| Rate for Payer: Frontpath All Commercial |
$3.66
|
| Rate for Payer: Humana ChoiceCare |
$3.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.58
|
| Rate for Payer: PHCS All Commercial |
$2.98
|
| Rate for Payer: PHP All Commercial |
$3.02
|
| Rate for Payer: Sagamore Health Network All Products |
$3.07
|
| Rate for Payer: Signature Care EPO |
$3.30
|
| Rate for Payer: Signature Care PPO |
$3.50
|
| Rate for Payer: United Healthcare Commercial |
$3.13
|
|
|
LACTOBACILLUS RHAMNOSUS GG 15 BILLION CELLS ORAL CPSP
|
Facility
OP
|
$3.98
|
|
|
Service Code
|
NDC 49100036374
|
| Hospital Charge Code |
164424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$3.70 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Aetna Medicare |
$1.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.49
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.51
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.44
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Centivo All Commercial |
$2.03
|
| Rate for Payer: Cigna All Commercial |
$3.43
|
| Rate for Payer: CORVEL All Commercial |
$3.70
|
| Rate for Payer: Coventry All Commercial |
$3.50
|
| Rate for Payer: Encore All Commercial |
$3.66
|
| Rate for Payer: Frontpath All Commercial |
$3.66
|
| Rate for Payer: Humana ChoiceCare |
$3.43
|
| Rate for Payer: Humana Medicare |
$2.03
|
| Rate for Payer: Lucent All Commercial |
$2.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.58
|
| Rate for Payer: PHCS All Commercial |
$2.98
|
| Rate for Payer: PHP All Commercial |
$3.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.55
|
| Rate for Payer: Sagamore Health Network All Products |
$3.07
|
| Rate for Payer: Signature Care EPO |
$3.30
|
| Rate for Payer: Signature Care PPO |
$3.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.38
|
| Rate for Payer: United Healthcare Commercial |
$3.13
|
| Rate for Payer: United Healthcare Medicare |
$1.31
|
|
|
LACTULOSE 10 GRAM/15 ML RETENTION ENEMA (CAMERON)
|
Facility
OP
|
$10.29
|
|
|
Service Code
|
NDC 00121115440
|
| Hospital Charge Code |
1401000601037
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$8.68
|
| Rate for Payer: Aetna Medicare |
$3.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.43
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.74
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: Centivo All Commercial |
$5.25
|
| Rate for Payer: Cigna All Commercial |
$8.88
|
| Rate for Payer: CORVEL All Commercial |
$9.57
|
| Rate for Payer: Coventry All Commercial |
$9.06
|
| Rate for Payer: Encore All Commercial |
$9.47
|
| Rate for Payer: Frontpath All Commercial |
$9.47
|
| Rate for Payer: Humana ChoiceCare |
$8.89
|
| Rate for Payer: Humana Medicare |
$5.25
|
| Rate for Payer: Lucent All Commercial |
$5.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.26
|
| Rate for Payer: PHCS All Commercial |
$7.72
|
| Rate for Payer: PHP All Commercial |
$7.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.01
|
| Rate for Payer: Sagamore Health Network All Products |
$7.94
|
| Rate for Payer: Signature Care EPO |
$8.54
|
| Rate for Payer: Signature Care PPO |
$9.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.75
|
| Rate for Payer: United Healthcare Commercial |
$8.11
|
| Rate for Payer: United Healthcare Medicare |
$3.40
|
|
|
LACTULOSE 10 GRAM/15 ML RETENTION ENEMA (CAMERON)
|
Facility
IP
|
$10.29
|
|
|
Service Code
|
NDC 00121115440
|
| Hospital Charge Code |
1401000601037
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$8.89
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: Cigna All Commercial |
$8.88
|
| Rate for Payer: CORVEL All Commercial |
$9.57
|
| Rate for Payer: Coventry All Commercial |
$9.06
|
| Rate for Payer: Encore All Commercial |
$9.47
|
| Rate for Payer: Frontpath All Commercial |
$9.47
|
| Rate for Payer: Humana ChoiceCare |
$8.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.26
|
| Rate for Payer: PHCS All Commercial |
$7.72
|
| Rate for Payer: PHP All Commercial |
$7.80
|
| Rate for Payer: Sagamore Health Network All Products |
$7.94
|
| Rate for Payer: Signature Care EPO |
$8.54
|
| Rate for Payer: Signature Care PPO |
$9.06
|
| Rate for Payer: United Healthcare Commercial |
$8.11
|
|
|
LACTULOSE 20 GRAM/30 ML ORAL SOLN
|
Facility
OP
|
$10.29
|
|
|
Service Code
|
NDC 00121115440
|
| Hospital Charge Code |
153619
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$8.68
|
| Rate for Payer: Aetna Medicare |
$3.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.43
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.74
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: Centivo All Commercial |
$5.25
|
| Rate for Payer: Cigna All Commercial |
$8.88
|
| Rate for Payer: CORVEL All Commercial |
$9.57
|
| Rate for Payer: Coventry All Commercial |
$9.06
|
| Rate for Payer: Encore All Commercial |
$9.47
|
| Rate for Payer: Frontpath All Commercial |
$9.47
|
| Rate for Payer: Humana ChoiceCare |
$8.89
|
| Rate for Payer: Humana Medicare |
$5.25
|
| Rate for Payer: Lucent All Commercial |
$5.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.26
|
| Rate for Payer: PHCS All Commercial |
$7.72
|
| Rate for Payer: PHP All Commercial |
$7.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.01
|
| Rate for Payer: Sagamore Health Network All Products |
$7.94
|
| Rate for Payer: Signature Care EPO |
$8.54
|
| Rate for Payer: Signature Care PPO |
$9.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.75
|
| Rate for Payer: United Healthcare Commercial |
$8.11
|
| Rate for Payer: United Healthcare Medicare |
$3.40
|
|
|
LACTULOSE 20 GRAM/30 ML ORAL SOLN
|
Facility
IP
|
$10.29
|
|
|
Service Code
|
NDC 00121115440
|
| Hospital Charge Code |
153619
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$8.89
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: Cigna All Commercial |
$8.88
|
| Rate for Payer: CORVEL All Commercial |
$9.57
|
| Rate for Payer: Coventry All Commercial |
$9.06
|
| Rate for Payer: Encore All Commercial |
$9.47
|
| Rate for Payer: Frontpath All Commercial |
$9.47
|
| Rate for Payer: Humana ChoiceCare |
$8.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.26
|
| Rate for Payer: PHCS All Commercial |
$7.72
|
| Rate for Payer: PHP All Commercial |
$7.80
|
| Rate for Payer: Sagamore Health Network All Products |
$7.94
|
| Rate for Payer: Signature Care EPO |
$8.54
|
| Rate for Payer: Signature Care PPO |
$9.06
|
| Rate for Payer: United Healthcare Commercial |
$8.11
|
|
|
LAMOTRIGINE 100 MG ORAL TAB
|
Facility
OP
|
$1.17
|
|
|
Service Code
|
NDC 68084031901
|
| Hospital Charge Code |
13982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna Commercial |
$0.99
|
| Rate for Payer: Aetna Medicare |
$0.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.73
|
| 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 |
$0.72
|
| Rate for Payer: Centivo All Commercial |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$1.01
|
| Rate for Payer: CORVEL All Commercial |
$1.09
|
| Rate for Payer: Coventry All Commercial |
$1.03
|
| Rate for Payer: Encore All Commercial |
$1.08
|
| Rate for Payer: Frontpath All Commercial |
$1.08
|
| Rate for Payer: Humana ChoiceCare |
$1.01
|
| Rate for Payer: Humana Medicare |
$0.60
|
| Rate for Payer: Lucent All Commercial |
$0.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.05
|
| Rate for Payer: PHCS All Commercial |
$0.88
|
| Rate for Payer: PHP All Commercial |
$0.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.46
|
| Rate for Payer: Sagamore Health Network All Products |
$0.90
|
| Rate for Payer: Signature Care EPO |
$0.97
|
| Rate for Payer: Signature Care PPO |
$1.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.99
|
| Rate for Payer: United Healthcare Commercial |
$0.92
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
|
|
LAMOTRIGINE 100 MG ORAL TAB
|
Facility
IP
|
$1.17
|
|
|
Service Code
|
NDC 68084031901
|
| Hospital Charge Code |
13982
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna Commercial |
$1.01
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna All Commercial |
$1.01
|
| Rate for Payer: CORVEL All Commercial |
$1.09
|
| Rate for Payer: Coventry All Commercial |
$1.03
|
| Rate for Payer: Encore All Commercial |
$1.08
|
| Rate for Payer: Frontpath All Commercial |
$1.08
|
| Rate for Payer: Humana ChoiceCare |
$1.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.05
|
| Rate for Payer: PHCS All Commercial |
$0.88
|
| Rate for Payer: PHP All Commercial |
$0.89
|
| Rate for Payer: Sagamore Health Network All Products |
$0.90
|
| Rate for Payer: Signature Care EPO |
$0.97
|
| Rate for Payer: Signature Care PPO |
$1.03
|
| Rate for Payer: United Healthcare Commercial |
$0.92
|
|
|
Laparoscopic treatment of ectopic pregnancy; with salpingectomy and/or oophorectomy
|
Facility
OP
|
$4,211.34
|
|
|
Service Code
|
CPT 59151
|
| Hospital Charge Code |
CPT-59151
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,211.34 |
| Max. Negotiated Rate |
$4,211.34 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,211.34
|
| Rate for Payer: Managed Health Services Medicaid |
$4,211.34
|
| Rate for Payer: MDWise Medicaid |
$4,211.34
|
|
|
Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 49320
|
| Hospital Charge Code |
CPT-49320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Laparoscopy, surgical, appendectomy
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 44970
|
| Hospital Charge Code |
CPT-44970
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,905.42 |
| Max. Negotiated Rate |
$1,905.42 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,905.42
|
| Rate for Payer: Managed Health Services Medicaid |
$1,905.42
|
| Rate for Payer: MDWise Medicaid |
$1,905.42
|
|
|
Laparoscopy, surgical; cholecystectomy
|
Facility
OP
|
$4,211.34
|
|
|
Service Code
|
CPT 47562
|
| Hospital Charge Code |
CPT-47562
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,211.34 |
| Max. Negotiated Rate |
$4,211.34 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4,211.34
|
| Rate for Payer: Managed Health Services Medicaid |
$4,211.34
|
| Rate for Payer: MDWise Medicaid |
$4,211.34
|
|
