|
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN
|
Facility
OP
|
$26.11
|
|
|
Service Code
|
NDC 63323049257
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$22.04
|
| 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 |
$14.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.32
|
| 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 |
$16.19
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Centivo All Commercial |
$13.32
|
| 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: Humana Medicare |
$13.32
|
| Rate for Payer: Lucent All Commercial |
$13.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.50
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$19.58
|
| Rate for Payer: PHP All Commercial |
$19.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.18
|
| 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: Three Rivers Preferred All Commercial |
$22.19
|
| Rate for Payer: United Healthcare Commercial |
$20.57
|
| Rate for Payer: United Healthcare Medicare |
$8.62
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN
|
Facility
IP
|
$39.48
|
|
|
Service Code
|
NDC 63323049297
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.61 |
| Max. Negotiated Rate |
$36.72 |
| Rate for Payer: Aetna Commercial |
$34.11
|
| Rate for Payer: Cash Price |
$24.48
|
| 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: Lutheran Preferred All Commercial |
$35.53
|
| Rate for Payer: PHCS All Commercial |
$29.61
|
| Rate for Payer: PHP All Commercial |
$29.94
|
| 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: United Healthcare Commercial |
$31.11
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN
|
Facility
OP
|
$23.84
|
|
|
Service Code
|
NDC 63323049507
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.87 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$20.12
|
| Rate for Payer: Aetna Medicare |
$7.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$13.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14.90
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.65
|
| Rate for Payer: Cash Price |
$14.78
|
| Rate for Payer: Cash Price |
$14.78
|
| Rate for Payer: Centivo All Commercial |
$12.16
|
| Rate for Payer: Cigna All Commercial |
$20.57
|
| Rate for Payer: CORVEL All Commercial |
$22.17
|
| Rate for Payer: Coventry All Commercial |
$20.97
|
| Rate for Payer: Encore All Commercial |
$21.94
|
| Rate for Payer: Frontpath All Commercial |
$21.93
|
| Rate for Payer: Humana ChoiceCare |
$20.59
|
| Rate for Payer: Humana Medicare |
$12.16
|
| Rate for Payer: Lucent All Commercial |
$12.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.45
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$17.88
|
| Rate for Payer: PHP All Commercial |
$18.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.30
|
| Rate for Payer: Sagamore Health Network All Products |
$18.40
|
| Rate for Payer: Signature Care EPO |
$19.78
|
| Rate for Payer: Signature Care PPO |
$20.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.26
|
| Rate for Payer: United Healthcare Commercial |
$18.78
|
| Rate for Payer: United Healthcare Medicare |
$7.87
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN
|
Facility
IP
|
$23.84
|
|
|
Service Code
|
NDC 63323049507
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.88 |
| Max. Negotiated Rate |
$22.17 |
| Rate for Payer: Aetna Commercial |
$20.59
|
| Rate for Payer: Cash Price |
$14.78
|
| Rate for Payer: Cigna All Commercial |
$20.57
|
| Rate for Payer: CORVEL All Commercial |
$22.17
|
| Rate for Payer: Coventry All Commercial |
$20.97
|
| Rate for Payer: Encore All Commercial |
$21.94
|
| Rate for Payer: Frontpath All Commercial |
$21.93
|
| Rate for Payer: Humana ChoiceCare |
$20.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.45
|
| Rate for Payer: PHCS All Commercial |
$17.88
|
| Rate for Payer: PHP All Commercial |
$18.08
|
| Rate for Payer: Sagamore Health Network All Products |
$18.40
|
| Rate for Payer: Signature Care EPO |
$19.78
|
| Rate for Payer: Signature Care PPO |
$20.97
|
| Rate for Payer: United Healthcare Commercial |
$18.78
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN
|
Facility
OP
|
$19.46
|
|
|
Service Code
|
NDC 63323049527
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$16.42
|
| Rate for Payer: Aetna Medicare |
$6.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.16
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.06
|
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: Centivo All Commercial |
$9.92
|
| Rate for Payer: Cigna All Commercial |
$16.79
|
| Rate for Payer: CORVEL All Commercial |
$18.10
|
| Rate for Payer: Coventry All Commercial |
$17.12
|
| Rate for Payer: Encore All Commercial |
$17.91
|
| Rate for Payer: Frontpath All Commercial |
$17.90
|
| Rate for Payer: Humana ChoiceCare |
$16.81
|
| Rate for Payer: Humana Medicare |
$9.92
|
| Rate for Payer: Lucent All Commercial |
$9.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.51
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$14.60
|
| Rate for Payer: PHP All Commercial |
$14.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.59
|
| Rate for Payer: Sagamore Health Network All Products |
$15.02
|
| Rate for Payer: Signature Care EPO |
$16.15
|
| Rate for Payer: Signature Care PPO |
$17.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.54
|
| Rate for Payer: United Healthcare Commercial |
$15.33
|
| Rate for Payer: United Healthcare Medicare |
$6.42
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN
|
Facility
IP
|
$19.46
|
|
|
Service Code
|
NDC 63323049527
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.60 |
| Max. Negotiated Rate |
$18.10 |
| Rate for Payer: Aetna Commercial |
$16.81
|
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: Cigna All Commercial |
$16.79
|
| Rate for Payer: CORVEL All Commercial |
$18.10
|
| Rate for Payer: Coventry All Commercial |
$17.12
|
| Rate for Payer: Encore All Commercial |
$17.91
|
| Rate for Payer: Frontpath All Commercial |
$17.90
|
| Rate for Payer: Humana ChoiceCare |
$16.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.51
|
| Rate for Payer: PHCS All Commercial |
$14.60
|
| Rate for Payer: PHP All Commercial |
$14.76
|
| Rate for Payer: Sagamore Health Network All Products |
$15.02
|
| Rate for Payer: Signature Care EPO |
$16.15
|
| Rate for Payer: Signature Care PPO |
$17.12
|
| Rate for Payer: United Healthcare Commercial |
$15.33
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) IV SOLN
|
Facility
OP
|
$22.79
|
|
|
Service Code
|
NDC 63323020805
|
| Hospital Charge Code |
118084
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$19.23
|
| Rate for Payer: Aetna Medicare |
$7.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$13.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14.24
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.27
|
| Rate for Payer: Cash Price |
$14.13
|
| Rate for Payer: Cash Price |
$14.13
|
| Rate for Payer: Centivo All Commercial |
$11.62
|
| Rate for Payer: Cigna All Commercial |
$19.66
|
| Rate for Payer: CORVEL All Commercial |
$21.19
|
| Rate for Payer: Coventry All Commercial |
$20.05
|
| Rate for Payer: Encore All Commercial |
$20.97
|
| Rate for Payer: Frontpath All Commercial |
$20.96
|
| Rate for Payer: Humana ChoiceCare |
$19.68
|
| Rate for Payer: Humana Medicare |
$11.62
|
| Rate for Payer: Lucent All Commercial |
$11.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.51
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$17.09
|
| Rate for Payer: PHP All Commercial |
$17.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.89
|
| Rate for Payer: Sagamore Health Network All Products |
$17.59
|
| Rate for Payer: Signature Care EPO |
$18.91
|
| Rate for Payer: Signature Care PPO |
$20.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$19.37
|
| Rate for Payer: United Healthcare Commercial |
$17.95
|
| Rate for Payer: United Healthcare Medicare |
$7.52
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) IV SOLN
|
Facility
IP
|
$22.79
|
|
|
Service Code
|
NDC 63323020805
|
| Hospital Charge Code |
118084
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.09 |
| Max. Negotiated Rate |
$21.19 |
| Rate for Payer: Aetna Commercial |
$19.69
|
| Rate for Payer: Cash Price |
$14.13
|
| Rate for Payer: Cigna All Commercial |
$19.66
|
| Rate for Payer: CORVEL All Commercial |
$21.19
|
| Rate for Payer: Coventry All Commercial |
$20.05
|
| Rate for Payer: Encore All Commercial |
$20.97
|
| Rate for Payer: Frontpath All Commercial |
$20.96
|
| Rate for Payer: Humana ChoiceCare |
$19.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.51
|
| Rate for Payer: PHCS All Commercial |
$17.09
|
| Rate for Payer: PHP All Commercial |
$17.28
|
| Rate for Payer: Sagamore Health Network All Products |
$17.59
|
| Rate for Payer: Signature Care EPO |
$18.91
|
| Rate for Payer: Signature Care PPO |
$20.05
|
| Rate for Payer: United Healthcare Commercial |
$17.95
|
|
|
LIDOCAINE (PF) 3.5 % OPHT GEL
|
Facility
IP
|
$155.12
|
|
|
Service Code
|
NDC 17478079201
|
| Hospital Charge Code |
94220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$116.34 |
| Max. Negotiated Rate |
$144.26 |
| Rate for Payer: Aetna Commercial |
$134.02
|
| Rate for Payer: Cash Price |
$96.17
|
| Rate for Payer: Cigna All Commercial |
$133.87
|
| Rate for Payer: CORVEL All Commercial |
$144.26
|
| Rate for Payer: Coventry All Commercial |
$136.51
|
| Rate for Payer: Encore All Commercial |
$142.79
|
| Rate for Payer: Frontpath All Commercial |
$142.71
|
| Rate for Payer: Humana ChoiceCare |
$133.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$139.61
|
| Rate for Payer: PHCS All Commercial |
$116.34
|
| Rate for Payer: PHP All Commercial |
$117.64
|
| Rate for Payer: Sagamore Health Network All Products |
$119.75
|
| Rate for Payer: Signature Care EPO |
$128.75
|
| Rate for Payer: Signature Care PPO |
$136.51
|
| Rate for Payer: United Healthcare Commercial |
$122.23
|
|
|
LIDOCAINE (PF) 3.5 % OPHT GEL
|
Facility
OP
|
$155.12
|
|
|
Service Code
|
NDC 17478079201
|
| Hospital Charge Code |
94220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$144.26 |
| Rate for Payer: Aetna Commercial |
$130.92
|
| Rate for Payer: Aetna Medicare |
$51.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$51.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$89.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$96.97
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$58.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$56.31
|
| Rate for Payer: Cash Price |
$96.17
|
| Rate for Payer: Cash Price |
$96.17
|
| Rate for Payer: Centivo All Commercial |
$79.11
|
| Rate for Payer: Cigna All Commercial |
$133.87
|
| Rate for Payer: CORVEL All Commercial |
$144.26
|
| Rate for Payer: Coventry All Commercial |
$136.51
|
| Rate for Payer: Encore All Commercial |
$142.79
|
| Rate for Payer: Frontpath All Commercial |
$142.71
|
| Rate for Payer: Humana ChoiceCare |
$133.98
|
| Rate for Payer: Humana Medicare |
$79.11
|
| Rate for Payer: Lucent All Commercial |
$79.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$139.61
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$116.34
|
| Rate for Payer: PHP All Commercial |
$117.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$60.50
|
| Rate for Payer: Sagamore Health Network All Products |
$119.75
|
| Rate for Payer: Signature Care EPO |
$128.75
|
| Rate for Payer: Signature Care PPO |
$136.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$131.85
|
| Rate for Payer: United Healthcare Commercial |
$122.23
|
| Rate for Payer: United Healthcare Medicare |
$51.19
|
|
|
LIDOCAINE (PF) 4 MG/ML (0.4 %) IV SOLP
|
Facility
OP
|
$56.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
14868
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.48 |
| Max. Negotiated Rate |
$52.08 |
| Rate for Payer: Aetna Commercial |
$47.26
|
| Rate for Payer: Aetna Medicare |
$18.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$32.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$35.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.33
|
| Rate for Payer: Cash Price |
$34.72
|
| Rate for Payer: Centivo All Commercial |
$28.56
|
| Rate for Payer: Cigna All Commercial |
$48.33
|
| Rate for Payer: CORVEL All Commercial |
$52.08
|
| Rate for Payer: Coventry All Commercial |
$49.28
|
| Rate for Payer: Encore All Commercial |
$51.55
|
| Rate for Payer: Frontpath All Commercial |
$51.52
|
| Rate for Payer: Humana ChoiceCare |
$48.37
|
| Rate for Payer: Humana Medicare |
$28.56
|
| Rate for Payer: Lucent All Commercial |
$28.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$50.40
|
| Rate for Payer: PHCS All Commercial |
$42.00
|
| Rate for Payer: PHP All Commercial |
$42.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$21.84
|
| Rate for Payer: Sagamore Health Network All Products |
$43.23
|
| Rate for Payer: Signature Care EPO |
$46.48
|
| Rate for Payer: Signature Care PPO |
$49.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$47.60
|
| Rate for Payer: United Healthcare Commercial |
$44.13
|
| Rate for Payer: United Healthcare Medicare |
$18.48
|
|
|
LIDOCAINE (PF) 4 MG/ML (0.4 %) IV SOLP
|
Facility
IP
|
$56.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
14868
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$52.08 |
| Rate for Payer: Aetna Commercial |
$48.38
|
| Rate for Payer: Cash Price |
$34.72
|
| Rate for Payer: Cigna All Commercial |
$48.33
|
| Rate for Payer: CORVEL All Commercial |
$52.08
|
| Rate for Payer: Coventry All Commercial |
$49.28
|
| Rate for Payer: Encore All Commercial |
$51.55
|
| Rate for Payer: Frontpath All Commercial |
$51.52
|
| Rate for Payer: Humana ChoiceCare |
$48.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$50.40
|
| Rate for Payer: PHCS All Commercial |
$42.00
|
| Rate for Payer: PHP All Commercial |
$42.47
|
| Rate for Payer: Sagamore Health Network All Products |
$43.23
|
| Rate for Payer: Signature Care EPO |
$46.48
|
| Rate for Payer: Signature Care PPO |
$49.28
|
| Rate for Payer: United Healthcare Commercial |
$44.13
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
105635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$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) 5 MG/ML (0.5 %) INJ SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
105635
|
|
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 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 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: 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: 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-PRILOCAINE 2.5-2.5 % TOP CREA
|
Facility
IP
|
$56.53
|
|
|
Service Code
|
NDC 00168035755
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.39 |
| Max. Negotiated Rate |
$52.57 |
| Rate for Payer: Aetna Commercial |
$48.84
|
| Rate for Payer: Cash Price |
$35.05
|
| Rate for Payer: Cigna All Commercial |
$48.78
|
| Rate for Payer: CORVEL All Commercial |
$52.57
|
| Rate for Payer: Coventry All Commercial |
$49.74
|
| Rate for Payer: Encore All Commercial |
$52.03
|
| Rate for Payer: Frontpath All Commercial |
$52.00
|
| Rate for Payer: Humana ChoiceCare |
$48.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$50.87
|
| Rate for Payer: PHCS All Commercial |
$42.39
|
| Rate for Payer: PHP All Commercial |
$42.87
|
| Rate for Payer: Sagamore Health Network All Products |
$43.64
|
| Rate for Payer: Signature Care EPO |
$46.92
|
| Rate for Payer: Signature Care PPO |
$49.74
|
| Rate for Payer: United Healthcare Commercial |
$44.54
|
|
|
LIDOCAINE-PRILOCAINE 2.5-2.5 % TOP CREA
|
Facility
OP
|
$56.53
|
|
|
Service Code
|
NDC 00168035755
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.65 |
| Max. Negotiated Rate |
$52.57 |
| Rate for Payer: Aetna Commercial |
$47.71
|
| Rate for Payer: Aetna Medicare |
$18.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$32.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$35.33
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.52
|
| Rate for Payer: Cash Price |
$35.05
|
| Rate for Payer: Centivo All Commercial |
$28.83
|
| Rate for Payer: Cigna All Commercial |
$48.78
|
| Rate for Payer: CORVEL All Commercial |
$52.57
|
| Rate for Payer: Coventry All Commercial |
$49.74
|
| Rate for Payer: Encore All Commercial |
$52.03
|
| Rate for Payer: Frontpath All Commercial |
$52.00
|
| Rate for Payer: Humana ChoiceCare |
$48.82
|
| Rate for Payer: Humana Medicare |
$28.83
|
| Rate for Payer: Lucent All Commercial |
$28.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$50.87
|
| Rate for Payer: PHCS All Commercial |
$42.39
|
| Rate for Payer: PHP All Commercial |
$42.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.04
|
| Rate for Payer: Sagamore Health Network All Products |
$43.64
|
| Rate for Payer: Signature Care EPO |
$46.92
|
| Rate for Payer: Signature Care PPO |
$49.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$48.05
|
| Rate for Payer: United Healthcare Commercial |
$44.54
|
| Rate for Payer: United Healthcare Medicare |
$18.65
|
|
|
LIDOCAINE-RACEPINEP-TETRACAINE 4-0.05-0.5 % TOP GEL
|
Facility
IP
|
$96.18
|
|
|
Service Code
|
NDC 70092161144
|
| Hospital Charge Code |
182360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$72.14 |
| Max. Negotiated Rate |
$89.45 |
| Rate for Payer: Aetna Commercial |
$83.10
|
| Rate for Payer: Cash Price |
$59.63
|
| Rate for Payer: Cigna All Commercial |
$83.00
|
| Rate for Payer: CORVEL All Commercial |
$89.45
|
| Rate for Payer: Coventry All Commercial |
$84.64
|
| Rate for Payer: Encore All Commercial |
$88.53
|
| Rate for Payer: Frontpath All Commercial |
$88.49
|
| Rate for Payer: Humana ChoiceCare |
$83.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$86.56
|
| Rate for Payer: PHCS All Commercial |
$72.14
|
| Rate for Payer: PHP All Commercial |
$72.94
|
| Rate for Payer: Sagamore Health Network All Products |
$74.25
|
| Rate for Payer: Signature Care EPO |
$79.83
|
| Rate for Payer: Signature Care PPO |
$84.64
|
| Rate for Payer: United Healthcare Commercial |
$75.79
|
|
|
LIDOCAINE-RACEPINEP-TETRACAINE 4-0.05-0.5 % TOP GEL
|
Facility
OP
|
$96.18
|
|
|
Service Code
|
NDC 70092161144
|
| Hospital Charge Code |
182360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.74 |
| Max. Negotiated Rate |
$89.45 |
| Rate for Payer: Aetna Commercial |
$81.18
|
| Rate for Payer: Aetna Medicare |
$31.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$55.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$60.12
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$36.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$34.91
|
| Rate for Payer: Cash Price |
$59.63
|
| Rate for Payer: Cash Price |
$59.63
|
| Rate for Payer: Centivo All Commercial |
$49.05
|
| Rate for Payer: Cigna All Commercial |
$83.00
|
| Rate for Payer: CORVEL All Commercial |
$89.45
|
| Rate for Payer: Coventry All Commercial |
$84.64
|
| Rate for Payer: Encore All Commercial |
$88.53
|
| Rate for Payer: Frontpath All Commercial |
$88.49
|
| Rate for Payer: Humana ChoiceCare |
$83.07
|
| Rate for Payer: Humana Medicare |
$49.05
|
| Rate for Payer: Lucent All Commercial |
$49.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$86.56
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$72.14
|
| Rate for Payer: PHP All Commercial |
$72.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$37.51
|
| Rate for Payer: Sagamore Health Network All Products |
$74.25
|
| Rate for Payer: Signature Care EPO |
$79.83
|
| Rate for Payer: Signature Care PPO |
$84.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$81.75
|
| Rate for Payer: United Healthcare Commercial |
$75.79
|
| Rate for Payer: United Healthcare Medicare |
$31.74
|
|
|
Ligamentous reconstruction (augmentation), knee; extra-articular
|
Facility
OP
|
$1,905.42
|
|
|
Service Code
|
CPT 27427
|
| Hospital Charge Code |
CPT-27427
|
|
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
|
|
|
LINEZOLID 600 MG ORAL TAB
|
Facility
OP
|
$17.71
|
|
|
Service Code
|
NDC 00904655304
|
| Hospital Charge Code |
28224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$16.47 |
| Rate for Payer: Aetna Commercial |
$14.95
|
| Rate for Payer: Aetna Medicare |
$5.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.43
|
| Rate for Payer: Cash Price |
$10.98
|
| Rate for Payer: Centivo All Commercial |
$9.03
|
| Rate for Payer: Cigna All Commercial |
$15.28
|
| Rate for Payer: CORVEL All Commercial |
$16.47
|
| Rate for Payer: Coventry All Commercial |
$15.58
|
| Rate for Payer: Encore All Commercial |
$16.30
|
| Rate for Payer: Frontpath All Commercial |
$16.29
|
| Rate for Payer: Humana ChoiceCare |
$15.30
|
| Rate for Payer: Humana Medicare |
$9.03
|
| Rate for Payer: Lucent All Commercial |
$9.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.94
|
| Rate for Payer: PHCS All Commercial |
$13.28
|
| Rate for Payer: PHP All Commercial |
$13.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.91
|
| Rate for Payer: Sagamore Health Network All Products |
$13.67
|
| Rate for Payer: Signature Care EPO |
$14.70
|
| Rate for Payer: Signature Care PPO |
$15.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.05
|
| Rate for Payer: United Healthcare Commercial |
$13.96
|
| Rate for Payer: United Healthcare Medicare |
$5.84
|
|
|
LINEZOLID 600 MG ORAL TAB
|
Facility
IP
|
$17.71
|
|
|
Service Code
|
NDC 00904655304
|
| Hospital Charge Code |
28224
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.28 |
| Max. Negotiated Rate |
$16.47 |
| Rate for Payer: Aetna Commercial |
$15.30
|
| Rate for Payer: Cash Price |
$10.98
|
| Rate for Payer: Cigna All Commercial |
$15.28
|
| Rate for Payer: CORVEL All Commercial |
$16.47
|
| Rate for Payer: Coventry All Commercial |
$15.58
|
| Rate for Payer: Encore All Commercial |
$16.30
|
| Rate for Payer: Frontpath All Commercial |
$16.29
|
| Rate for Payer: Humana ChoiceCare |
$15.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.94
|
| Rate for Payer: PHCS All Commercial |
$13.28
|
| Rate for Payer: PHP All Commercial |
$13.43
|
| Rate for Payer: Sagamore Health Network All Products |
$13.67
|
| Rate for Payer: Signature Care EPO |
$14.70
|
| Rate for Payer: Signature Care PPO |
$15.58
|
| Rate for Payer: United Healthcare Commercial |
$13.96
|
|
|
LINEZOLID IN DEXTROSE 5% 600 MG/300 ML IV PGBK
|
Facility
IP
|
$147.00
|
|
|
Service Code
|
HCPCS J2020
|
| Hospital Charge Code |
114051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$110.25 |
| Max. Negotiated Rate |
$136.71 |
| Rate for Payer: Aetna Commercial |
$127.01
|
| Rate for Payer: Cash Price |
$91.14
|
| Rate for Payer: Cigna All Commercial |
$126.86
|
| Rate for Payer: CORVEL All Commercial |
$136.71
|
| Rate for Payer: Coventry All Commercial |
$129.36
|
| Rate for Payer: Encore All Commercial |
$135.31
|
| Rate for Payer: Frontpath All Commercial |
$135.24
|
| Rate for Payer: Humana ChoiceCare |
$126.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.30
|
| Rate for Payer: PHCS All Commercial |
$110.25
|
| Rate for Payer: PHP All Commercial |
$111.48
|
| Rate for Payer: Sagamore Health Network All Products |
$113.48
|
| Rate for Payer: Signature Care EPO |
$122.01
|
| Rate for Payer: Signature Care PPO |
$129.36
|
| Rate for Payer: United Healthcare Commercial |
$115.84
|
|
|
LINEZOLID IN DEXTROSE 5% 600 MG/300 ML IV PGBK
|
Facility
OP
|
$147.00
|
|
|
Service Code
|
HCPCS J2020
|
| Hospital Charge Code |
114051
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.51 |
| Max. Negotiated Rate |
$136.71 |
| Rate for Payer: Aetna Commercial |
$124.07
|
| Rate for Payer: Aetna Medicare |
$48.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$48.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$84.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$91.89
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$55.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$53.36
|
| Rate for Payer: Cash Price |
$91.14
|
| Rate for Payer: Centivo All Commercial |
$74.97
|
| Rate for Payer: Cigna All Commercial |
$126.86
|
| Rate for Payer: CORVEL All Commercial |
$136.71
|
| Rate for Payer: Coventry All Commercial |
$129.36
|
| Rate for Payer: Encore All Commercial |
$135.31
|
| Rate for Payer: Frontpath All Commercial |
$135.24
|
| Rate for Payer: Humana ChoiceCare |
$126.96
|
| Rate for Payer: Humana Medicare |
$74.97
|
| Rate for Payer: Lucent All Commercial |
$74.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.30
|
| Rate for Payer: PHCS All Commercial |
$110.25
|
| Rate for Payer: PHP All Commercial |
$111.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$57.33
|
| Rate for Payer: Sagamore Health Network All Products |
$113.48
|
| Rate for Payer: Signature Care EPO |
$122.01
|
| Rate for Payer: Signature Care PPO |
$129.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$124.95
|
| Rate for Payer: United Healthcare Commercial |
$115.84
|
| Rate for Payer: United Healthcare Medicare |
$48.51
|
|
|
LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBQ PNIJ
|
Facility
OP
|
$839.48
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
100803
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$277.03 |
| Max. Negotiated Rate |
$780.71 |
| Rate for Payer: Aetna Commercial |
$708.52
|
| Rate for Payer: Aetna Medicare |
$277.03
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$277.03
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$482.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$524.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$318.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$304.73
|
| Rate for Payer: Cash Price |
$520.47
|
| Rate for Payer: Centivo All Commercial |
$428.13
|
| Rate for Payer: Cigna All Commercial |
$724.47
|
| Rate for Payer: CORVEL All Commercial |
$780.71
|
| Rate for Payer: Coventry All Commercial |
$738.74
|
| Rate for Payer: Encore All Commercial |
$772.74
|
| Rate for Payer: Frontpath All Commercial |
$772.32
|
| Rate for Payer: Humana ChoiceCare |
$725.05
|
| Rate for Payer: Humana Medicare |
$428.13
|
| Rate for Payer: Lucent All Commercial |
$428.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$755.53
|
| Rate for Payer: PHCS All Commercial |
$629.61
|
| Rate for Payer: PHP All Commercial |
$636.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$327.40
|
| Rate for Payer: Sagamore Health Network All Products |
$648.07
|
| Rate for Payer: Signature Care EPO |
$696.76
|
| Rate for Payer: Signature Care PPO |
$738.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$713.55
|
| Rate for Payer: United Healthcare Commercial |
$661.51
|
| Rate for Payer: United Healthcare Medicare |
$277.03
|
|
|
LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBQ PNIJ
|
Facility
IP
|
$839.48
|
|
|
Service Code
|
HCPCS C9399
|
| Hospital Charge Code |
100803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$629.61 |
| Max. Negotiated Rate |
$780.71 |
| Rate for Payer: Aetna Commercial |
$725.31
|
| Rate for Payer: Cash Price |
$520.47
|
| Rate for Payer: Cigna All Commercial |
$724.47
|
| Rate for Payer: CORVEL All Commercial |
$780.71
|
| Rate for Payer: Coventry All Commercial |
$738.74
|
| Rate for Payer: Encore All Commercial |
$772.74
|
| Rate for Payer: Frontpath All Commercial |
$772.32
|
| Rate for Payer: Humana ChoiceCare |
$725.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$755.53
|
| Rate for Payer: PHCS All Commercial |
$629.61
|
| Rate for Payer: PHP All Commercial |
$636.66
|
| Rate for Payer: Sagamore Health Network All Products |
$648.07
|
| Rate for Payer: Signature Care EPO |
$696.76
|
| Rate for Payer: Signature Care PPO |
$738.74
|
| Rate for Payer: United Healthcare Commercial |
$661.51
|
|
