|
LEVONORGESTREL 13.5 MG IUD 14 MCG/DAY (3 YEARS)
|
Facility
OP
|
$2,119.08
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
162367
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$699.30 |
| Max. Negotiated Rate |
$1,970.75 |
| Rate for Payer: Aetna Commercial |
$1,788.51
|
| Rate for Payer: Aetna Medicare |
$699.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$699.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,216.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,324.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$963.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$804.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$769.23
|
| Rate for Payer: Cash Price |
$1,313.83
|
| Rate for Payer: Cash Price |
$1,313.83
|
| Rate for Payer: Centivo All Commercial |
$1,080.73
|
| Rate for Payer: Cigna All Commercial |
$1,828.77
|
| Rate for Payer: CORVEL All Commercial |
$1,970.75
|
| Rate for Payer: Coventry All Commercial |
$1,864.79
|
| Rate for Payer: Encore All Commercial |
$1,950.62
|
| Rate for Payer: Frontpath All Commercial |
$1,949.56
|
| Rate for Payer: Humana ChoiceCare |
$1,830.25
|
| Rate for Payer: Humana Medicare |
$1,080.73
|
| Rate for Payer: Lucent All Commercial |
$1,080.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,907.18
|
| Rate for Payer: Managed Health Services Medicaid |
$963.22
|
| Rate for Payer: MDWise Medicaid |
$963.22
|
| Rate for Payer: PHCS All Commercial |
$1,589.31
|
| Rate for Payer: PHP All Commercial |
$1,607.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$826.44
|
| Rate for Payer: Sagamore Health Network All Products |
$1,635.93
|
| Rate for Payer: Signature Care EPO |
$1,758.84
|
| Rate for Payer: Signature Care PPO |
$1,864.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,801.22
|
| Rate for Payer: United Healthcare Commercial |
$1,669.84
|
| Rate for Payer: United Healthcare Medicare |
$699.30
|
|
|
LEVONORGESTREL 1.5 MG ORAL TAB
|
Facility
OP
|
$85.40
|
|
|
Service Code
|
NDC 68180085211
|
| Hospital Charge Code |
99445
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.18 |
| Max. Negotiated Rate |
$79.42 |
| Rate for Payer: Aetna Commercial |
$72.08
|
| Rate for Payer: Aetna Medicare |
$28.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$28.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$49.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$53.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$32.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$31.00
|
| Rate for Payer: Cash Price |
$52.95
|
| Rate for Payer: Centivo All Commercial |
$43.55
|
| Rate for Payer: Cigna All Commercial |
$73.70
|
| Rate for Payer: CORVEL All Commercial |
$79.42
|
| Rate for Payer: Coventry All Commercial |
$75.15
|
| Rate for Payer: Encore All Commercial |
$78.61
|
| Rate for Payer: Frontpath All Commercial |
$78.57
|
| Rate for Payer: Humana ChoiceCare |
$73.76
|
| Rate for Payer: Humana Medicare |
$43.55
|
| Rate for Payer: Lucent All Commercial |
$43.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$76.86
|
| Rate for Payer: PHCS All Commercial |
$64.05
|
| Rate for Payer: PHP All Commercial |
$64.77
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$33.31
|
| Rate for Payer: Sagamore Health Network All Products |
$65.93
|
| Rate for Payer: Signature Care EPO |
$70.88
|
| Rate for Payer: Signature Care PPO |
$75.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$72.59
|
| Rate for Payer: United Healthcare Commercial |
$67.30
|
| Rate for Payer: United Healthcare Medicare |
$28.18
|
|
|
LEVONORGESTREL 1.5 MG ORAL TAB
|
Facility
IP
|
$85.40
|
|
|
Service Code
|
NDC 68180085211
|
| Hospital Charge Code |
99445
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.05 |
| Max. Negotiated Rate |
$79.42 |
| Rate for Payer: Aetna Commercial |
$73.79
|
| Rate for Payer: Cash Price |
$52.95
|
| Rate for Payer: Cigna All Commercial |
$73.70
|
| Rate for Payer: CORVEL All Commercial |
$79.42
|
| Rate for Payer: Coventry All Commercial |
$75.15
|
| Rate for Payer: Encore All Commercial |
$78.61
|
| Rate for Payer: Frontpath All Commercial |
$78.57
|
| Rate for Payer: Humana ChoiceCare |
$73.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$76.86
|
| Rate for Payer: PHCS All Commercial |
$64.05
|
| Rate for Payer: PHP All Commercial |
$64.77
|
| Rate for Payer: Sagamore Health Network All Products |
$65.93
|
| Rate for Payer: Signature Care EPO |
$70.88
|
| Rate for Payer: Signature Care PPO |
$75.15
|
| Rate for Payer: United Healthcare Commercial |
$67.30
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (5 YRS) 19.5 MG IU IUD
|
Facility
IP
|
$2,544.94
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
179201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,908.70 |
| Max. Negotiated Rate |
$2,366.79 |
| Rate for Payer: Aetna Commercial |
$2,198.83
|
| Rate for Payer: Cash Price |
$1,577.86
|
| Rate for Payer: Cigna All Commercial |
$2,196.28
|
| Rate for Payer: CORVEL All Commercial |
$2,366.79
|
| Rate for Payer: Coventry All Commercial |
$2,239.55
|
| Rate for Payer: Encore All Commercial |
$2,342.62
|
| Rate for Payer: Frontpath All Commercial |
$2,341.34
|
| Rate for Payer: Humana ChoiceCare |
$2,198.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,290.44
|
| Rate for Payer: PHCS All Commercial |
$1,908.70
|
| Rate for Payer: PHP All Commercial |
$1,930.08
|
| Rate for Payer: Sagamore Health Network All Products |
$1,964.69
|
| Rate for Payer: Signature Care EPO |
$2,112.30
|
| Rate for Payer: Signature Care PPO |
$2,239.55
|
| Rate for Payer: United Healthcare Commercial |
$2,005.41
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (5 YRS) 19.5 MG IU IUD
|
Facility
OP
|
$2,544.94
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
179201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$839.83 |
| Max. Negotiated Rate |
$2,366.79 |
| Rate for Payer: Aetna Commercial |
$2,147.93
|
| Rate for Payer: Aetna Medicare |
$839.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$839.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,461.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,590.84
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,156.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$965.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$923.81
|
| Rate for Payer: Cash Price |
$1,577.86
|
| Rate for Payer: Cash Price |
$1,577.86
|
| Rate for Payer: Centivo All Commercial |
$1,297.92
|
| Rate for Payer: Cigna All Commercial |
$2,196.28
|
| Rate for Payer: CORVEL All Commercial |
$2,366.79
|
| Rate for Payer: Coventry All Commercial |
$2,239.55
|
| Rate for Payer: Encore All Commercial |
$2,342.62
|
| Rate for Payer: Frontpath All Commercial |
$2,341.34
|
| Rate for Payer: Humana ChoiceCare |
$2,198.06
|
| Rate for Payer: Humana Medicare |
$1,297.92
|
| Rate for Payer: Lucent All Commercial |
$1,297.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,290.44
|
| Rate for Payer: Managed Health Services Medicaid |
$1,156.79
|
| Rate for Payer: MDWise Medicaid |
$1,156.79
|
| Rate for Payer: PHCS All Commercial |
$1,908.70
|
| Rate for Payer: PHP All Commercial |
$1,930.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$992.53
|
| Rate for Payer: Sagamore Health Network All Products |
$1,964.69
|
| Rate for Payer: Signature Care EPO |
$2,112.30
|
| Rate for Payer: Signature Care PPO |
$2,239.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,163.20
|
| Rate for Payer: United Healthcare Commercial |
$2,005.41
|
| Rate for Payer: United Healthcare Medicare |
$839.83
|
|
|
LEVONORGESTREL 1 EACH IU IUD
|
Facility
OP
|
$2,544.94
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
29280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$839.83 |
| Max. Negotiated Rate |
$2,366.79 |
| Rate for Payer: Aetna Commercial |
$2,147.93
|
| Rate for Payer: Aetna Medicare |
$839.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$839.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,461.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,590.84
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,156.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$965.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$923.81
|
| Rate for Payer: Cash Price |
$1,577.86
|
| Rate for Payer: Cash Price |
$1,577.86
|
| Rate for Payer: Centivo All Commercial |
$1,297.92
|
| Rate for Payer: Cigna All Commercial |
$2,196.28
|
| Rate for Payer: CORVEL All Commercial |
$2,366.79
|
| Rate for Payer: Coventry All Commercial |
$2,239.55
|
| Rate for Payer: Encore All Commercial |
$2,342.62
|
| Rate for Payer: Frontpath All Commercial |
$2,341.34
|
| Rate for Payer: Humana ChoiceCare |
$2,198.06
|
| Rate for Payer: Humana Medicare |
$1,297.92
|
| Rate for Payer: Lucent All Commercial |
$1,297.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,290.44
|
| Rate for Payer: Managed Health Services Medicaid |
$1,156.79
|
| Rate for Payer: MDWise Medicaid |
$1,156.79
|
| Rate for Payer: PHCS All Commercial |
$1,908.70
|
| Rate for Payer: PHP All Commercial |
$1,930.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$992.53
|
| Rate for Payer: Sagamore Health Network All Products |
$1,964.69
|
| Rate for Payer: Signature Care EPO |
$2,112.30
|
| Rate for Payer: Signature Care PPO |
$2,239.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,163.20
|
| Rate for Payer: United Healthcare Commercial |
$2,005.41
|
| Rate for Payer: United Healthcare Medicare |
$839.83
|
|
|
LEVONORGESTREL 1 EACH IU IUD
|
Facility
IP
|
$2,544.94
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
29280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,908.70 |
| Max. Negotiated Rate |
$2,366.79 |
| Rate for Payer: Aetna Commercial |
$2,198.83
|
| Rate for Payer: Cash Price |
$1,577.86
|
| Rate for Payer: Cigna All Commercial |
$2,196.28
|
| Rate for Payer: CORVEL All Commercial |
$2,366.79
|
| Rate for Payer: Coventry All Commercial |
$2,239.55
|
| Rate for Payer: Encore All Commercial |
$2,342.62
|
| Rate for Payer: Frontpath All Commercial |
$2,341.34
|
| Rate for Payer: Humana ChoiceCare |
$2,198.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,290.44
|
| Rate for Payer: PHCS All Commercial |
$1,908.70
|
| Rate for Payer: PHP All Commercial |
$1,930.08
|
| Rate for Payer: Sagamore Health Network All Products |
$1,964.69
|
| Rate for Payer: Signature Care EPO |
$2,112.30
|
| Rate for Payer: Signature Care PPO |
$2,239.55
|
| Rate for Payer: United Healthcare Commercial |
$2,005.41
|
|
|
LEVOTHYROXINE 100 MCG ORAL TAB
|
Facility
OP
|
$2.91
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$2.71 |
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: Aetna Medicare |
$0.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.82
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.06
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Centivo All Commercial |
$1.49
|
| Rate for Payer: Cigna All Commercial |
$2.51
|
| Rate for Payer: CORVEL All Commercial |
$2.71
|
| Rate for Payer: Coventry All Commercial |
$2.56
|
| Rate for Payer: Encore All Commercial |
$2.68
|
| Rate for Payer: Frontpath All Commercial |
$2.68
|
| Rate for Payer: Humana ChoiceCare |
$2.52
|
| Rate for Payer: Humana Medicare |
$1.49
|
| Rate for Payer: Lucent All Commercial |
$1.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.62
|
| Rate for Payer: PHCS All Commercial |
$2.18
|
| Rate for Payer: PHP All Commercial |
$2.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.14
|
| Rate for Payer: Sagamore Health Network All Products |
$2.25
|
| Rate for Payer: Signature Care EPO |
$2.42
|
| Rate for Payer: Signature Care PPO |
$2.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.48
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
| Rate for Payer: United Healthcare Medicare |
$0.96
|
|
|
LEVOTHYROXINE 100 MCG ORAL TAB
|
Facility
IP
|
$2.91
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$2.71 |
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: Cash Price |
$1.81
|
| Rate for Payer: Cigna All Commercial |
$2.51
|
| Rate for Payer: CORVEL All Commercial |
$2.71
|
| Rate for Payer: Coventry All Commercial |
$2.56
|
| Rate for Payer: Encore All Commercial |
$2.68
|
| Rate for Payer: Frontpath All Commercial |
$2.68
|
| Rate for Payer: Humana ChoiceCare |
$2.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.62
|
| Rate for Payer: PHCS All Commercial |
$2.18
|
| Rate for Payer: PHP All Commercial |
$2.21
|
| Rate for Payer: Sagamore Health Network All Products |
$2.25
|
| Rate for Payer: Signature Care EPO |
$2.42
|
| Rate for Payer: Signature Care PPO |
$2.56
|
| Rate for Payer: United Healthcare Commercial |
$2.29
|
|
|
LEVOTHYROXINE 200 MCG IV SOLR
|
Facility
IP
|
$1,001.45
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
4418
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$751.09 |
| Max. Negotiated Rate |
$931.35 |
| Rate for Payer: Aetna Commercial |
$865.25
|
| Rate for Payer: Cash Price |
$620.90
|
| Rate for Payer: Cigna All Commercial |
$864.25
|
| Rate for Payer: CORVEL All Commercial |
$931.35
|
| Rate for Payer: Coventry All Commercial |
$881.28
|
| Rate for Payer: Encore All Commercial |
$921.83
|
| Rate for Payer: Frontpath All Commercial |
$921.33
|
| Rate for Payer: Humana ChoiceCare |
$864.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$901.30
|
| Rate for Payer: PHCS All Commercial |
$751.09
|
| Rate for Payer: PHP All Commercial |
$759.50
|
| Rate for Payer: Sagamore Health Network All Products |
$773.12
|
| Rate for Payer: Signature Care EPO |
$831.20
|
| Rate for Payer: Signature Care PPO |
$881.28
|
| Rate for Payer: United Healthcare Commercial |
$789.14
|
|
|
LEVOTHYROXINE 200 MCG IV SOLR
|
Facility
OP
|
$1,001.45
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
4418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$330.48 |
| Max. Negotiated Rate |
$931.35 |
| Rate for Payer: Aetna Commercial |
$845.22
|
| Rate for Payer: Aetna Medicare |
$330.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$330.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$575.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$626.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$380.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$363.53
|
| Rate for Payer: Cash Price |
$620.90
|
| Rate for Payer: Centivo All Commercial |
$510.74
|
| Rate for Payer: Cigna All Commercial |
$864.25
|
| Rate for Payer: CORVEL All Commercial |
$931.35
|
| Rate for Payer: Coventry All Commercial |
$881.28
|
| Rate for Payer: Encore All Commercial |
$921.83
|
| Rate for Payer: Frontpath All Commercial |
$921.33
|
| Rate for Payer: Humana ChoiceCare |
$864.95
|
| Rate for Payer: Humana Medicare |
$510.74
|
| Rate for Payer: Lucent All Commercial |
$510.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$901.30
|
| Rate for Payer: PHCS All Commercial |
$751.09
|
| Rate for Payer: PHP All Commercial |
$759.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$390.57
|
| Rate for Payer: Sagamore Health Network All Products |
$773.12
|
| Rate for Payer: Signature Care EPO |
$831.20
|
| Rate for Payer: Signature Care PPO |
$881.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$851.23
|
| Rate for Payer: United Healthcare Commercial |
$789.14
|
| Rate for Payer: United Healthcare Medicare |
$330.48
|
|
|
LEVOTHYROXINE 25 MCG ORAL TAB
|
Facility
IP
|
$3.23
|
|
|
Service Code
|
NDC 51079044420
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Aetna Commercial |
$2.79
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Cigna All Commercial |
$2.78
|
| Rate for Payer: CORVEL All Commercial |
$3.00
|
| Rate for Payer: Coventry All Commercial |
$2.84
|
| Rate for Payer: Encore All Commercial |
$2.97
|
| Rate for Payer: Frontpath All Commercial |
$2.97
|
| Rate for Payer: Humana ChoiceCare |
$2.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.90
|
| Rate for Payer: PHCS All Commercial |
$2.42
|
| Rate for Payer: PHP All Commercial |
$2.45
|
| Rate for Payer: Sagamore Health Network All Products |
$2.49
|
| Rate for Payer: Signature Care EPO |
$2.68
|
| Rate for Payer: Signature Care PPO |
$2.84
|
| Rate for Payer: United Healthcare Commercial |
$2.54
|
|
|
LEVOTHYROXINE 25 MCG ORAL TAB
|
Facility
OP
|
$3.23
|
|
|
Service Code
|
NDC 51079044420
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Aetna Commercial |
$2.72
|
| Rate for Payer: Aetna Medicare |
$1.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.02
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.17
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Centivo All Commercial |
$1.65
|
| Rate for Payer: Cigna All Commercial |
$2.78
|
| Rate for Payer: CORVEL All Commercial |
$3.00
|
| Rate for Payer: Coventry All Commercial |
$2.84
|
| Rate for Payer: Encore All Commercial |
$2.97
|
| Rate for Payer: Frontpath All Commercial |
$2.97
|
| Rate for Payer: Humana ChoiceCare |
$2.79
|
| Rate for Payer: Humana Medicare |
$1.65
|
| Rate for Payer: Lucent All Commercial |
$1.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.90
|
| Rate for Payer: PHCS All Commercial |
$2.42
|
| Rate for Payer: PHP All Commercial |
$2.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.26
|
| Rate for Payer: Sagamore Health Network All Products |
$2.49
|
| Rate for Payer: Signature Care EPO |
$2.68
|
| Rate for Payer: Signature Care PPO |
$2.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.74
|
| Rate for Payer: United Healthcare Commercial |
$2.54
|
| Rate for Payer: United Healthcare Medicare |
$1.06
|
|
|
LEVOTHYROXINE 88 MCG ORAL TAB
|
Facility
IP
|
$2.86
|
|
|
Service Code
|
NDC 00904695261
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Aetna Commercial |
$2.47
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna All Commercial |
$2.46
|
| Rate for Payer: CORVEL All Commercial |
$2.66
|
| Rate for Payer: Coventry All Commercial |
$2.51
|
| Rate for Payer: Encore All Commercial |
$2.63
|
| Rate for Payer: Frontpath All Commercial |
$2.63
|
| Rate for Payer: Humana ChoiceCare |
$2.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.57
|
| Rate for Payer: PHCS All Commercial |
$2.14
|
| Rate for Payer: PHP All Commercial |
$2.17
|
| Rate for Payer: Sagamore Health Network All Products |
$2.20
|
| Rate for Payer: Signature Care EPO |
$2.37
|
| Rate for Payer: Signature Care PPO |
$2.51
|
| Rate for Payer: United Healthcare Commercial |
$2.25
|
|
|
LEVOTHYROXINE 88 MCG ORAL TAB
|
Facility
OP
|
$2.86
|
|
|
Service Code
|
NDC 00904695261
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Aetna Commercial |
$2.41
|
| Rate for Payer: Aetna Medicare |
$0.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.04
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Centivo All Commercial |
$1.46
|
| Rate for Payer: Cigna All Commercial |
$2.46
|
| Rate for Payer: CORVEL All Commercial |
$2.66
|
| Rate for Payer: Coventry All Commercial |
$2.51
|
| Rate for Payer: Encore All Commercial |
$2.63
|
| Rate for Payer: Frontpath All Commercial |
$2.63
|
| Rate for Payer: Humana ChoiceCare |
$2.47
|
| Rate for Payer: Humana Medicare |
$1.46
|
| Rate for Payer: Lucent All Commercial |
$1.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.57
|
| Rate for Payer: PHCS All Commercial |
$2.14
|
| Rate for Payer: PHP All Commercial |
$2.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.11
|
| Rate for Payer: Sagamore Health Network All Products |
$2.20
|
| Rate for Payer: Signature Care EPO |
$2.37
|
| Rate for Payer: Signature Care PPO |
$2.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.43
|
| Rate for Payer: United Healthcare Commercial |
$2.25
|
| Rate for Payer: United Healthcare Medicare |
$0.94
|
|
|
LIDOCAINE 4 % TOP PTMD
|
Facility
IP
|
$7.40
|
|
|
Service Code
|
NDC 00536120207
|
| Hospital Charge Code |
110425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.55 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Aetna Commercial |
$6.39
|
| Rate for Payer: Cash Price |
$4.59
|
| Rate for Payer: Cigna All Commercial |
$6.39
|
| Rate for Payer: CORVEL All Commercial |
$6.88
|
| Rate for Payer: Coventry All Commercial |
$6.51
|
| Rate for Payer: Encore All Commercial |
$6.81
|
| Rate for Payer: Frontpath All Commercial |
$6.81
|
| Rate for Payer: Humana ChoiceCare |
$6.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.66
|
| Rate for Payer: PHCS All Commercial |
$5.55
|
| Rate for Payer: PHP All Commercial |
$5.61
|
| Rate for Payer: Sagamore Health Network All Products |
$5.71
|
| Rate for Payer: Signature Care EPO |
$6.14
|
| Rate for Payer: Signature Care PPO |
$6.51
|
| Rate for Payer: United Healthcare Commercial |
$5.83
|
|
|
LIDOCAINE 4 % TOP PTMD
|
Facility
OP
|
$7.40
|
|
|
Service Code
|
NDC 00536120207
|
| Hospital Charge Code |
110425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.44 |
| Max. Negotiated Rate |
$6.88 |
| Rate for Payer: Aetna Commercial |
$6.24
|
| Rate for Payer: Aetna Medicare |
$2.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.69
|
| Rate for Payer: Cash Price |
$4.59
|
| Rate for Payer: Centivo All Commercial |
$3.77
|
| Rate for Payer: Cigna All Commercial |
$6.39
|
| Rate for Payer: CORVEL All Commercial |
$6.88
|
| Rate for Payer: Coventry All Commercial |
$6.51
|
| Rate for Payer: Encore All Commercial |
$6.81
|
| Rate for Payer: Frontpath All Commercial |
$6.81
|
| Rate for Payer: Humana ChoiceCare |
$6.39
|
| Rate for Payer: Humana Medicare |
$3.77
|
| Rate for Payer: Lucent All Commercial |
$3.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.66
|
| Rate for Payer: PHCS All Commercial |
$5.55
|
| Rate for Payer: PHP All Commercial |
$5.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.89
|
| Rate for Payer: Sagamore Health Network All Products |
$5.71
|
| Rate for Payer: Signature Care EPO |
$6.14
|
| Rate for Payer: Signature Care PPO |
$6.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.29
|
| Rate for Payer: United Healthcare Commercial |
$5.83
|
| Rate for Payer: United Healthcare Medicare |
$2.44
|
|
|
LIDOCAINE 5 % TOP PTMD
|
Facility
OP
|
$11.63
|
|
|
Service Code
|
NDC 00591352530
|
| Hospital Charge Code |
28203
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$10.81 |
| Rate for Payer: Aetna Commercial |
$9.81
|
| Rate for Payer: Aetna Medicare |
$3.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.22
|
| Rate for Payer: Cash Price |
$7.21
|
| Rate for Payer: Centivo All Commercial |
$5.93
|
| Rate for Payer: Cigna All Commercial |
$10.03
|
| Rate for Payer: CORVEL All Commercial |
$10.81
|
| Rate for Payer: Coventry All Commercial |
$10.23
|
| Rate for Payer: Encore All Commercial |
$10.70
|
| Rate for Payer: Frontpath All Commercial |
$10.70
|
| Rate for Payer: Humana ChoiceCare |
$10.04
|
| Rate for Payer: Humana Medicare |
$5.93
|
| Rate for Payer: Lucent All Commercial |
$5.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.46
|
| Rate for Payer: PHCS All Commercial |
$8.72
|
| Rate for Payer: PHP All Commercial |
$8.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.53
|
| Rate for Payer: Sagamore Health Network All Products |
$8.98
|
| Rate for Payer: Signature Care EPO |
$9.65
|
| Rate for Payer: Signature Care PPO |
$10.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9.88
|
| Rate for Payer: United Healthcare Commercial |
$9.16
|
| Rate for Payer: United Healthcare Medicare |
$3.84
|
|
|
LIDOCAINE 5 % TOP PTMD
|
Facility
IP
|
$11.63
|
|
|
Service Code
|
NDC 00591352530
|
| Hospital Charge Code |
28203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$10.81 |
| Rate for Payer: Aetna Commercial |
$10.05
|
| Rate for Payer: Cash Price |
$7.21
|
| Rate for Payer: Cigna All Commercial |
$10.03
|
| Rate for Payer: CORVEL All Commercial |
$10.81
|
| Rate for Payer: Coventry All Commercial |
$10.23
|
| Rate for Payer: Encore All Commercial |
$10.70
|
| Rate for Payer: Frontpath All Commercial |
$10.70
|
| Rate for Payer: Humana ChoiceCare |
$10.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.46
|
| Rate for Payer: PHCS All Commercial |
$8.72
|
| Rate for Payer: PHP All Commercial |
$8.82
|
| Rate for Payer: Sagamore Health Network All Products |
$8.98
|
| Rate for Payer: Signature Care EPO |
$9.65
|
| Rate for Payer: Signature Care PPO |
$10.23
|
| Rate for Payer: United Healthcare Commercial |
$9.16
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
NDC 00409317803
|
| Hospital Charge Code |
10427
|
|
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 |
$11.16
|
| 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-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
IP
|
$30.87
|
|
|
Service Code
|
NDC 00409317802
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.15 |
| Max. Negotiated Rate |
$28.71 |
| Rate for Payer: Aetna Commercial |
$26.67
|
| Rate for Payer: Cash Price |
$19.14
|
| Rate for Payer: Cigna All Commercial |
$26.64
|
| Rate for Payer: CORVEL All Commercial |
$28.71
|
| Rate for Payer: Coventry All Commercial |
$27.17
|
| Rate for Payer: Encore All Commercial |
$28.42
|
| Rate for Payer: Frontpath All Commercial |
$28.40
|
| Rate for Payer: Humana ChoiceCare |
$26.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.78
|
| Rate for Payer: PHCS All Commercial |
$23.15
|
| Rate for Payer: PHP All Commercial |
$23.41
|
| Rate for Payer: Sagamore Health Network All Products |
$23.83
|
| Rate for Payer: Signature Care EPO |
$25.62
|
| Rate for Payer: Signature Care PPO |
$27.17
|
| Rate for Payer: United Healthcare Commercial |
$24.33
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
NDC 00409317803
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| 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: Cash Price |
$11.16
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| 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 |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| 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 |
$5.94
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
IP
|
$23.03
|
|
|
Service Code
|
NDC 63323048217
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$21.42 |
| Rate for Payer: Aetna Commercial |
$19.90
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Cigna All Commercial |
$19.87
|
| Rate for Payer: CORVEL All Commercial |
$21.42
|
| Rate for Payer: Coventry All Commercial |
$20.27
|
| Rate for Payer: Encore All Commercial |
$21.20
|
| Rate for Payer: Frontpath All Commercial |
$21.19
|
| Rate for Payer: Humana ChoiceCare |
$19.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.73
|
| Rate for Payer: PHCS All Commercial |
$17.27
|
| Rate for Payer: PHP All Commercial |
$17.47
|
| Rate for Payer: Sagamore Health Network All Products |
$17.78
|
| Rate for Payer: Signature Care EPO |
$19.11
|
| Rate for Payer: Signature Care PPO |
$20.27
|
| Rate for Payer: United Healthcare Commercial |
$18.15
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
IP
|
$32.62
|
|
|
Service Code
|
NDC 63323048227
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$30.34 |
| Rate for Payer: Aetna Commercial |
$28.18
|
| Rate for Payer: Cash Price |
$20.22
|
| Rate for Payer: Cigna All Commercial |
$28.15
|
| Rate for Payer: CORVEL All Commercial |
$30.34
|
| Rate for Payer: Coventry All Commercial |
$28.71
|
| Rate for Payer: Encore All Commercial |
$30.03
|
| Rate for Payer: Frontpath All Commercial |
$30.01
|
| Rate for Payer: Humana ChoiceCare |
$28.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.36
|
| Rate for Payer: PHCS All Commercial |
$24.46
|
| Rate for Payer: PHP All Commercial |
$24.74
|
| Rate for Payer: Sagamore Health Network All Products |
$25.18
|
| Rate for Payer: Signature Care EPO |
$27.07
|
| Rate for Payer: Signature Care PPO |
$28.71
|
| Rate for Payer: United Healthcare Commercial |
$25.70
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN
|
Facility
OP
|
$23.03
|
|
|
Service Code
|
NDC 63323048217
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.60 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$19.44
|
| Rate for Payer: Aetna Medicare |
$7.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$13.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14.40
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.36
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Centivo All Commercial |
$11.75
|
| Rate for Payer: Cigna All Commercial |
$19.87
|
| Rate for Payer: CORVEL All Commercial |
$21.42
|
| Rate for Payer: Coventry All Commercial |
$20.27
|
| Rate for Payer: Encore All Commercial |
$21.20
|
| Rate for Payer: Frontpath All Commercial |
$21.19
|
| Rate for Payer: Humana ChoiceCare |
$19.89
|
| Rate for Payer: Humana Medicare |
$11.75
|
| Rate for Payer: Lucent All Commercial |
$11.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.73
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$17.27
|
| Rate for Payer: PHP All Commercial |
$17.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.98
|
| Rate for Payer: Sagamore Health Network All Products |
$17.78
|
| Rate for Payer: Signature Care EPO |
$19.11
|
| Rate for Payer: Signature Care PPO |
$20.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$19.58
|
| Rate for Payer: United Healthcare Commercial |
$18.15
|
| Rate for Payer: United Healthcare Medicare |
$7.60
|
|
