|
LIDOCAINE HCL 2 % MM JELL
|
Facility
IP
|
$46.48
|
|
|
Service Code
|
NDC 17478071131
|
| Hospital Charge Code |
4448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.86 |
| Max. Negotiated Rate |
$43.23 |
| Rate for Payer: Aetna Commercial |
$40.16
|
| Rate for Payer: Cash Price |
$28.82
|
| Rate for Payer: Cigna All Commercial |
$40.11
|
| Rate for Payer: CORVEL All Commercial |
$43.23
|
| Rate for Payer: Coventry All Commercial |
$40.90
|
| Rate for Payer: Encore All Commercial |
$42.78
|
| Rate for Payer: Frontpath All Commercial |
$42.76
|
| Rate for Payer: Humana ChoiceCare |
$40.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$41.83
|
| Rate for Payer: PHCS All Commercial |
$34.86
|
| Rate for Payer: PHP All Commercial |
$35.25
|
| Rate for Payer: Sagamore Health Network All Products |
$35.88
|
| Rate for Payer: Signature Care EPO |
$38.58
|
| Rate for Payer: Signature Care PPO |
$40.90
|
| Rate for Payer: United Healthcare Commercial |
$36.63
|
|
|
LIDOCAINE HCL 2 % MM JELP
|
Facility
OP
|
$53.83
|
|
|
Service Code
|
NDC 76329301305
|
| Hospital Charge Code |
120006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.76 |
| Max. Negotiated Rate |
$50.06 |
| Rate for Payer: Aetna Commercial |
$45.43
|
| Rate for Payer: Aetna Medicare |
$17.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$30.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$33.65
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$20.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.54
|
| Rate for Payer: Cash Price |
$33.37
|
| Rate for Payer: Cash Price |
$33.37
|
| Rate for Payer: Centivo All Commercial |
$27.45
|
| Rate for Payer: Cigna All Commercial |
$46.46
|
| Rate for Payer: CORVEL All Commercial |
$50.06
|
| Rate for Payer: Coventry All Commercial |
$47.37
|
| Rate for Payer: Encore All Commercial |
$49.55
|
| Rate for Payer: Frontpath All Commercial |
$49.52
|
| Rate for Payer: Humana ChoiceCare |
$46.49
|
| Rate for Payer: Humana Medicare |
$27.45
|
| Rate for Payer: Lucent All Commercial |
$27.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.45
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$40.37
|
| Rate for Payer: PHP All Commercial |
$40.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$20.99
|
| Rate for Payer: Sagamore Health Network All Products |
$41.56
|
| Rate for Payer: Signature Care EPO |
$44.68
|
| Rate for Payer: Signature Care PPO |
$47.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$45.76
|
| Rate for Payer: United Healthcare Commercial |
$42.42
|
| Rate for Payer: United Healthcare Medicare |
$17.76
|
|
|
LIDOCAINE HCL 2 % MM JELP
|
Facility
IP
|
$53.83
|
|
|
Service Code
|
NDC 76329301305
|
| Hospital Charge Code |
120006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.37 |
| Max. Negotiated Rate |
$50.06 |
| Rate for Payer: Aetna Commercial |
$46.51
|
| Rate for Payer: Cash Price |
$33.37
|
| Rate for Payer: Cigna All Commercial |
$46.46
|
| Rate for Payer: CORVEL All Commercial |
$50.06
|
| Rate for Payer: Coventry All Commercial |
$47.37
|
| Rate for Payer: Encore All Commercial |
$49.55
|
| Rate for Payer: Frontpath All Commercial |
$49.52
|
| Rate for Payer: Humana ChoiceCare |
$46.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.45
|
| Rate for Payer: PHCS All Commercial |
$40.37
|
| Rate for Payer: PHP All Commercial |
$40.82
|
| Rate for Payer: Sagamore Health Network All Products |
$41.56
|
| Rate for Payer: Signature Care EPO |
$44.68
|
| Rate for Payer: Signature Care PPO |
$47.37
|
| Rate for Payer: United Healthcare Commercial |
$42.42
|
|
|
LIDOCAINE HCL 2 % MM JELP
|
Facility
IP
|
$26.12
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
120006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.59 |
| Max. Negotiated Rate |
$24.30 |
| Rate for Payer: Aetna Commercial |
$22.57
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna All Commercial |
$22.55
|
| Rate for Payer: CORVEL All Commercial |
$24.30
|
| Rate for Payer: Coventry All Commercial |
$22.99
|
| Rate for Payer: Encore All Commercial |
$24.05
|
| Rate for Payer: Frontpath All Commercial |
$24.03
|
| Rate for Payer: Humana ChoiceCare |
$22.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.51
|
| Rate for Payer: PHCS All Commercial |
$19.59
|
| Rate for Payer: PHP All Commercial |
$19.81
|
| Rate for Payer: Sagamore Health Network All Products |
$20.17
|
| Rate for Payer: Signature Care EPO |
$21.68
|
| Rate for Payer: Signature Care PPO |
$22.99
|
| Rate for Payer: United Healthcare Commercial |
$20.59
|
|
|
LIDOCAINE HCL 2 % MM JELP
|
Facility
OP
|
$26.12
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
120006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$22.05
|
| Rate for Payer: Aetna Medicare |
$8.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$15.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.33
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.48
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Centivo All Commercial |
$13.32
|
| Rate for Payer: Cigna All Commercial |
$22.55
|
| Rate for Payer: CORVEL All Commercial |
$24.30
|
| Rate for Payer: Coventry All Commercial |
$22.99
|
| Rate for Payer: Encore All Commercial |
$24.05
|
| Rate for Payer: Frontpath All Commercial |
$24.03
|
| Rate for Payer: Humana ChoiceCare |
$22.56
|
| Rate for Payer: Humana Medicare |
$13.32
|
| Rate for Payer: Lucent All Commercial |
$13.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.51
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$19.59
|
| Rate for Payer: PHP All Commercial |
$19.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.19
|
| Rate for Payer: Sagamore Health Network All Products |
$20.17
|
| Rate for Payer: Signature Care EPO |
$21.68
|
| Rate for Payer: Signature Care PPO |
$22.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22.21
|
| Rate for Payer: United Healthcare Commercial |
$20.59
|
| Rate for Payer: United Healthcare Medicare |
$8.62
|
|
|
LIDOCAINE HCL 2 % MM SOLN
|
Facility
IP
|
$5.04
|
|
|
Service Code
|
NDC 50383036317
|
| Hospital Charge Code |
111639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.78 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$4.35
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cigna All Commercial |
$4.35
|
| Rate for Payer: CORVEL All Commercial |
$4.69
|
| Rate for Payer: Coventry All Commercial |
$4.44
|
| Rate for Payer: Encore All Commercial |
$4.64
|
| Rate for Payer: Frontpath All Commercial |
$4.64
|
| Rate for Payer: Humana ChoiceCare |
$4.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.54
|
| Rate for Payer: PHCS All Commercial |
$3.78
|
| Rate for Payer: PHP All Commercial |
$3.82
|
| Rate for Payer: Sagamore Health Network All Products |
$3.89
|
| Rate for Payer: Signature Care EPO |
$4.18
|
| Rate for Payer: Signature Care PPO |
$4.44
|
| Rate for Payer: United Healthcare Commercial |
$3.97
|
|
|
LIDOCAINE HCL 2 % MM SOLN
|
Facility
OP
|
$66.50
|
|
|
Service Code
|
NDC 00054350049
|
| Hospital Charge Code |
111639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.94 |
| Max. Negotiated Rate |
$61.84 |
| Rate for Payer: Aetna Commercial |
$56.13
|
| Rate for Payer: Aetna Medicare |
$21.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$38.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$41.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$25.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.14
|
| Rate for Payer: Cash Price |
$41.23
|
| Rate for Payer: Centivo All Commercial |
$33.92
|
| Rate for Payer: Cigna All Commercial |
$57.39
|
| Rate for Payer: CORVEL All Commercial |
$61.84
|
| Rate for Payer: Coventry All Commercial |
$58.52
|
| Rate for Payer: Encore All Commercial |
$61.21
|
| Rate for Payer: Frontpath All Commercial |
$61.18
|
| Rate for Payer: Humana ChoiceCare |
$57.44
|
| Rate for Payer: Humana Medicare |
$33.92
|
| Rate for Payer: Lucent All Commercial |
$33.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.85
|
| Rate for Payer: PHCS All Commercial |
$49.88
|
| Rate for Payer: PHP All Commercial |
$50.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$25.94
|
| Rate for Payer: Sagamore Health Network All Products |
$51.34
|
| Rate for Payer: Signature Care EPO |
$55.20
|
| Rate for Payer: Signature Care PPO |
$58.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$56.52
|
| Rate for Payer: United Healthcare Commercial |
$52.40
|
| Rate for Payer: United Healthcare Medicare |
$21.94
|
|
|
LIDOCAINE HCL 2 % MM SOLN
|
Facility
OP
|
$5.04
|
|
|
Service Code
|
NDC 50383036317
|
| Hospital Charge Code |
111639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$4.25
|
| Rate for Payer: Aetna Medicare |
$1.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.83
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Centivo All Commercial |
$2.57
|
| Rate for Payer: Cigna All Commercial |
$4.35
|
| Rate for Payer: CORVEL All Commercial |
$4.69
|
| Rate for Payer: Coventry All Commercial |
$4.44
|
| Rate for Payer: Encore All Commercial |
$4.64
|
| Rate for Payer: Frontpath All Commercial |
$4.64
|
| Rate for Payer: Humana ChoiceCare |
$4.35
|
| Rate for Payer: Humana Medicare |
$2.57
|
| Rate for Payer: Lucent All Commercial |
$2.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.54
|
| Rate for Payer: PHCS All Commercial |
$3.78
|
| Rate for Payer: PHP All Commercial |
$3.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.97
|
| Rate for Payer: Sagamore Health Network All Products |
$3.89
|
| Rate for Payer: Signature Care EPO |
$4.18
|
| Rate for Payer: Signature Care PPO |
$4.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.28
|
| Rate for Payer: United Healthcare Commercial |
$3.97
|
| Rate for Payer: United Healthcare Medicare |
$1.66
|
|
|
LIDOCAINE HCL 2 % MM SOLN
|
Facility
IP
|
$66.50
|
|
|
Service Code
|
NDC 00054350049
|
| Hospital Charge Code |
111639
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.88 |
| Max. Negotiated Rate |
$61.84 |
| Rate for Payer: Aetna Commercial |
$57.46
|
| Rate for Payer: Cash Price |
$41.23
|
| Rate for Payer: Cigna All Commercial |
$57.39
|
| Rate for Payer: CORVEL All Commercial |
$61.84
|
| Rate for Payer: Coventry All Commercial |
$58.52
|
| Rate for Payer: Encore All Commercial |
$61.21
|
| Rate for Payer: Frontpath All Commercial |
$61.18
|
| Rate for Payer: Humana ChoiceCare |
$57.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.85
|
| Rate for Payer: PHCS All Commercial |
$49.88
|
| Rate for Payer: PHP All Commercial |
$50.43
|
| Rate for Payer: Sagamore Health Network All Products |
$51.34
|
| Rate for Payer: Signature Care EPO |
$55.20
|
| Rate for Payer: Signature Care PPO |
$58.52
|
| Rate for Payer: United Healthcare Commercial |
$52.40
|
|
|
LIDOCAINE HCL 2 % MM SOLN (UD)
|
Facility
OP
|
$5.04
|
|
|
Service Code
|
NDC 50383077517
|
| Hospital Charge Code |
800672
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$4.25
|
| Rate for Payer: Aetna Medicare |
$1.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.15
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.83
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Centivo All Commercial |
$2.57
|
| Rate for Payer: Cigna All Commercial |
$4.35
|
| Rate for Payer: CORVEL All Commercial |
$4.69
|
| Rate for Payer: Coventry All Commercial |
$4.44
|
| Rate for Payer: Encore All Commercial |
$4.64
|
| Rate for Payer: Frontpath All Commercial |
$4.64
|
| Rate for Payer: Humana ChoiceCare |
$4.35
|
| Rate for Payer: Humana Medicare |
$2.57
|
| Rate for Payer: Lucent All Commercial |
$2.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.54
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$3.78
|
| Rate for Payer: PHP All Commercial |
$3.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.97
|
| Rate for Payer: Sagamore Health Network All Products |
$3.89
|
| Rate for Payer: Signature Care EPO |
$4.18
|
| Rate for Payer: Signature Care PPO |
$4.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.28
|
| Rate for Payer: United Healthcare Commercial |
$3.97
|
| Rate for Payer: United Healthcare Medicare |
$1.66
|
|
|
LIDOCAINE HCL 2 % MM SOLN (UD)
|
Facility
IP
|
$5.04
|
|
|
Service Code
|
NDC 50383077517
|
| Hospital Charge Code |
800672
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.78 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$4.35
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cigna All Commercial |
$4.35
|
| Rate for Payer: CORVEL All Commercial |
$4.69
|
| Rate for Payer: Coventry All Commercial |
$4.44
|
| Rate for Payer: Encore All Commercial |
$4.64
|
| Rate for Payer: Frontpath All Commercial |
$4.64
|
| Rate for Payer: Humana ChoiceCare |
$4.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.54
|
| Rate for Payer: PHCS All Commercial |
$3.78
|
| Rate for Payer: PHP All Commercial |
$3.82
|
| Rate for Payer: Sagamore Health Network All Products |
$3.89
|
| Rate for Payer: Signature Care EPO |
$4.18
|
| Rate for Payer: Signature Care PPO |
$4.44
|
| Rate for Payer: United Healthcare Commercial |
$3.97
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MM SOLN
|
Facility
OP
|
$266.00
|
|
|
Service Code
|
NDC 00054350547
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$247.38 |
| Rate for Payer: Aetna Commercial |
$224.50
|
| Rate for Payer: Aetna Medicare |
$87.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$87.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$152.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$166.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$100.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$96.56
|
| Rate for Payer: Cash Price |
$164.92
|
| Rate for Payer: Cash Price |
$164.92
|
| Rate for Payer: Centivo All Commercial |
$135.66
|
| Rate for Payer: Cigna All Commercial |
$229.56
|
| Rate for Payer: CORVEL All Commercial |
$247.38
|
| Rate for Payer: Coventry All Commercial |
$234.08
|
| Rate for Payer: Encore All Commercial |
$244.85
|
| Rate for Payer: Frontpath All Commercial |
$244.72
|
| Rate for Payer: Humana ChoiceCare |
$229.74
|
| Rate for Payer: Humana Medicare |
$135.66
|
| Rate for Payer: Lucent All Commercial |
$135.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$239.40
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$199.50
|
| Rate for Payer: PHP All Commercial |
$201.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$103.74
|
| Rate for Payer: Sagamore Health Network All Products |
$205.35
|
| Rate for Payer: Signature Care EPO |
$220.78
|
| Rate for Payer: Signature Care PPO |
$234.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$226.10
|
| Rate for Payer: United Healthcare Commercial |
$209.61
|
| Rate for Payer: United Healthcare Medicare |
$87.78
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MM SOLN
|
Facility
IP
|
$266.00
|
|
|
Service Code
|
NDC 00054350547
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$199.50 |
| Max. Negotiated Rate |
$247.38 |
| Rate for Payer: Aetna Commercial |
$229.82
|
| Rate for Payer: Cash Price |
$164.92
|
| Rate for Payer: Cigna All Commercial |
$229.56
|
| Rate for Payer: CORVEL All Commercial |
$247.38
|
| Rate for Payer: Coventry All Commercial |
$234.08
|
| Rate for Payer: Encore All Commercial |
$244.85
|
| Rate for Payer: Frontpath All Commercial |
$244.72
|
| Rate for Payer: Humana ChoiceCare |
$229.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$239.40
|
| Rate for Payer: PHCS All Commercial |
$199.50
|
| Rate for Payer: PHP All Commercial |
$201.73
|
| Rate for Payer: Sagamore Health Network All Products |
$205.35
|
| Rate for Payer: Signature Care EPO |
$220.78
|
| Rate for Payer: Signature Care PPO |
$234.08
|
| Rate for Payer: United Healthcare Commercial |
$209.61
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MM SOLN FOR ENT USE (CAMERON)
|
Facility
OP
|
$606.00
|
|
|
Service Code
|
NDC 000543505
|
| Hospital Charge Code |
14010004450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$563.58 |
| Rate for Payer: Aetna Commercial |
$511.46
|
| Rate for Payer: Aetna Medicare |
$199.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$199.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$348.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$378.81
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$229.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$219.98
|
| Rate for Payer: Cash Price |
$375.72
|
| Rate for Payer: Cash Price |
$375.72
|
| Rate for Payer: Centivo All Commercial |
$309.06
|
| Rate for Payer: Cigna All Commercial |
$522.98
|
| Rate for Payer: CORVEL All Commercial |
$563.58
|
| Rate for Payer: Coventry All Commercial |
$533.28
|
| Rate for Payer: Encore All Commercial |
$557.82
|
| Rate for Payer: Frontpath All Commercial |
$557.52
|
| Rate for Payer: Humana ChoiceCare |
$523.40
|
| Rate for Payer: Humana Medicare |
$309.06
|
| Rate for Payer: Lucent All Commercial |
$309.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$545.40
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$454.50
|
| Rate for Payer: PHP All Commercial |
$459.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$236.34
|
| Rate for Payer: Sagamore Health Network All Products |
$467.83
|
| Rate for Payer: Signature Care EPO |
$502.98
|
| Rate for Payer: Signature Care PPO |
$533.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$515.10
|
| Rate for Payer: United Healthcare Commercial |
$477.53
|
| Rate for Payer: United Healthcare Medicare |
$199.98
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MM SOLN FOR ENT USE (CAMERON)
|
Facility
IP
|
$606.00
|
|
|
Service Code
|
NDC 000543505
|
| Hospital Charge Code |
14010004450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$454.50 |
| Max. Negotiated Rate |
$563.58 |
| Rate for Payer: Aetna Commercial |
$523.58
|
| Rate for Payer: Cash Price |
$375.72
|
| Rate for Payer: Cigna All Commercial |
$522.98
|
| Rate for Payer: CORVEL All Commercial |
$563.58
|
| Rate for Payer: Coventry All Commercial |
$533.28
|
| Rate for Payer: Encore All Commercial |
$557.82
|
| Rate for Payer: Frontpath All Commercial |
$557.52
|
| Rate for Payer: Humana ChoiceCare |
$523.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$545.40
|
| Rate for Payer: PHCS All Commercial |
$454.50
|
| Rate for Payer: PHP All Commercial |
$459.59
|
| Rate for Payer: Sagamore Health Network All Products |
$467.83
|
| Rate for Payer: Signature Care EPO |
$502.98
|
| Rate for Payer: Signature Care PPO |
$533.28
|
| Rate for Payer: United Healthcare Commercial |
$477.53
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRG
|
Facility
OP
|
$44.03
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
4459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$40.95 |
| Rate for Payer: Aetna Commercial |
$37.16
|
| Rate for Payer: Aetna Medicare |
$14.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$25.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$27.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$16.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.98
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Centivo All Commercial |
$22.46
|
| Rate for Payer: Cigna All Commercial |
$38.00
|
| Rate for Payer: CORVEL All Commercial |
$40.95
|
| Rate for Payer: Coventry All Commercial |
$38.75
|
| Rate for Payer: Encore All Commercial |
$40.53
|
| Rate for Payer: Frontpath All Commercial |
$40.51
|
| Rate for Payer: Humana ChoiceCare |
$38.03
|
| Rate for Payer: Humana Medicare |
$22.46
|
| Rate for Payer: Lucent All Commercial |
$22.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$39.63
|
| Rate for Payer: PHCS All Commercial |
$33.02
|
| Rate for Payer: PHP All Commercial |
$33.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$17.17
|
| Rate for Payer: Sagamore Health Network All Products |
$33.99
|
| Rate for Payer: Signature Care EPO |
$36.54
|
| Rate for Payer: Signature Care PPO |
$38.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$37.43
|
| Rate for Payer: United Healthcare Commercial |
$34.70
|
| Rate for Payer: United Healthcare Medicare |
$14.53
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRG
|
Facility
IP
|
$44.03
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
4459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.02 |
| Max. Negotiated Rate |
$40.95 |
| Rate for Payer: Aetna Commercial |
$38.04
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cigna All Commercial |
$38.00
|
| Rate for Payer: CORVEL All Commercial |
$40.95
|
| Rate for Payer: Coventry All Commercial |
$38.75
|
| Rate for Payer: Encore All Commercial |
$40.53
|
| Rate for Payer: Frontpath All Commercial |
$40.51
|
| Rate for Payer: Humana ChoiceCare |
$38.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$39.63
|
| Rate for Payer: PHCS All Commercial |
$33.02
|
| Rate for Payer: PHP All Commercial |
$33.39
|
| Rate for Payer: Sagamore Health Network All Products |
$33.99
|
| Rate for Payer: Signature Care EPO |
$36.54
|
| Rate for Payer: Signature Care PPO |
$38.75
|
| Rate for Payer: United Healthcare Commercial |
$34.70
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRG - FOR PAIN IVPB (CAMERON)
|
Facility
IP
|
$42.04
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
14010004459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.53 |
| Max. Negotiated Rate |
$39.09 |
| Rate for Payer: Aetna Commercial |
$36.32
|
| Rate for Payer: Cash Price |
$26.06
|
| Rate for Payer: Cigna All Commercial |
$36.28
|
| Rate for Payer: CORVEL All Commercial |
$39.09
|
| Rate for Payer: Coventry All Commercial |
$36.99
|
| Rate for Payer: Encore All Commercial |
$38.69
|
| Rate for Payer: Frontpath All Commercial |
$38.67
|
| Rate for Payer: Humana ChoiceCare |
$36.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.83
|
| Rate for Payer: PHCS All Commercial |
$31.53
|
| Rate for Payer: PHP All Commercial |
$31.88
|
| Rate for Payer: Sagamore Health Network All Products |
$32.45
|
| Rate for Payer: Signature Care EPO |
$34.89
|
| Rate for Payer: Signature Care PPO |
$36.99
|
| Rate for Payer: United Healthcare Commercial |
$33.12
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRG - FOR PAIN IVPB (CAMERON)
|
Facility
OP
|
$42.04
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
14010004459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.87 |
| Max. Negotiated Rate |
$39.09 |
| Rate for Payer: Aetna Commercial |
$35.48
|
| Rate for Payer: Aetna Medicare |
$13.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.26
|
| Rate for Payer: Cash Price |
$26.06
|
| Rate for Payer: Centivo All Commercial |
$21.44
|
| Rate for Payer: Cigna All Commercial |
$36.28
|
| Rate for Payer: CORVEL All Commercial |
$39.09
|
| Rate for Payer: Coventry All Commercial |
$36.99
|
| Rate for Payer: Encore All Commercial |
$38.69
|
| Rate for Payer: Frontpath All Commercial |
$38.67
|
| Rate for Payer: Humana ChoiceCare |
$36.31
|
| Rate for Payer: Humana Medicare |
$21.44
|
| Rate for Payer: Lucent All Commercial |
$21.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.83
|
| Rate for Payer: PHCS All Commercial |
$31.53
|
| Rate for Payer: PHP All Commercial |
$31.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.39
|
| Rate for Payer: Sagamore Health Network All Products |
$32.45
|
| Rate for Payer: Signature Care EPO |
$34.89
|
| Rate for Payer: Signature Care PPO |
$36.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.73
|
| Rate for Payer: United Healthcare Commercial |
$33.12
|
| Rate for Payer: United Healthcare Medicare |
$13.87
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN
|
Facility
OP
|
$39.48
|
|
|
Service Code
|
NDC 63323049297
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$33.32
|
| Rate for Payer: Aetna Medicare |
$13.03
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.03
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$22.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.68
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.33
|
| Rate for Payer: Cash Price |
$24.48
|
| Rate for Payer: Cash Price |
$24.48
|
| Rate for Payer: Centivo All Commercial |
$20.13
|
| Rate for Payer: Cigna All Commercial |
$34.07
|
| Rate for Payer: CORVEL All Commercial |
$36.72
|
| Rate for Payer: Coventry All Commercial |
$34.74
|
| Rate for Payer: Encore All Commercial |
$36.34
|
| Rate for Payer: Frontpath All Commercial |
$36.32
|
| Rate for Payer: Humana ChoiceCare |
$34.10
|
| Rate for Payer: Humana Medicare |
$20.13
|
| Rate for Payer: Lucent All Commercial |
$20.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.53
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$29.61
|
| Rate for Payer: PHP All Commercial |
$29.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.40
|
| Rate for Payer: Sagamore Health Network All Products |
$30.48
|
| Rate for Payer: Signature Care EPO |
$32.77
|
| Rate for Payer: Signature Care PPO |
$34.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$33.56
|
| Rate for Payer: United Healthcare Commercial |
$31.11
|
| Rate for Payer: United Healthcare Medicare |
$13.03
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
NDC 00409427902
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: 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 (PF) 10 MG/ML (1 %) INJ SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
NDC 00409427902
|
| Hospital Charge Code |
103888
|
|
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 (PF) 10 MG/ML (1 %) INJ SOLN
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
NDC 63323049227
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: 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 (PF) 10 MG/ML (1 %) INJ SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
NDC 63323049227
|
| Hospital Charge Code |
103888
|
|
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 (PF) 10 MG/ML (1 %) INJ SOLN
|
Facility
IP
|
$26.11
|
|
|
Service Code
|
NDC 63323049257
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.58 |
| Max. Negotiated Rate |
$24.28 |
| Rate for Payer: Aetna Commercial |
$22.56
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cigna All Commercial |
$22.53
|
| Rate for Payer: CORVEL All Commercial |
$24.28
|
| Rate for Payer: Coventry All Commercial |
$22.98
|
| Rate for Payer: Encore All Commercial |
$24.03
|
| Rate for Payer: Frontpath All Commercial |
$24.02
|
| Rate for Payer: Humana ChoiceCare |
$22.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.50
|
| Rate for Payer: PHCS All Commercial |
$19.58
|
| Rate for Payer: PHP All Commercial |
$19.80
|
| Rate for Payer: Sagamore Health Network All Products |
$20.16
|
| Rate for Payer: Signature Care EPO |
$21.67
|
| Rate for Payer: Signature Care PPO |
$22.98
|
| Rate for Payer: United Healthcare Commercial |
$20.57
|
|
