|
SILVER NITRATE APPLICATORS 75-25 % TOP STCK (CAMERON)
|
Facility
OP
|
$1.60
|
|
|
Service Code
|
NDC 12165010001
|
| Hospital Charge Code |
140100011359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$1.35
|
| Rate for Payer: Aetna Medicare |
$0.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Centivo All Commercial |
$0.81
|
| Rate for Payer: Cigna All Commercial |
$1.38
|
| Rate for Payer: CORVEL All Commercial |
$1.48
|
| Rate for Payer: Coventry All Commercial |
$1.40
|
| Rate for Payer: Encore All Commercial |
$1.47
|
| Rate for Payer: Frontpath All Commercial |
$1.47
|
| Rate for Payer: Humana ChoiceCare |
$1.38
|
| Rate for Payer: Humana Medicare |
$0.81
|
| Rate for Payer: Lucent All Commercial |
$0.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.44
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$1.20
|
| Rate for Payer: PHP All Commercial |
$1.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.62
|
| Rate for Payer: Sagamore Health Network All Products |
$1.23
|
| Rate for Payer: Signature Care EPO |
$1.32
|
| Rate for Payer: Signature Care PPO |
$1.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.36
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
| Rate for Payer: United Healthcare Medicare |
$0.53
|
|
|
SILVER NITRATE APPLICATORS 75-25 % TOP STCK (CAMERON)
|
Facility
IP
|
$1.60
|
|
|
Service Code
|
NDC 12165010001
|
| Hospital Charge Code |
140100011359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna Commercial |
$1.38
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cigna All Commercial |
$1.38
|
| Rate for Payer: CORVEL All Commercial |
$1.48
|
| Rate for Payer: Coventry All Commercial |
$1.40
|
| Rate for Payer: Encore All Commercial |
$1.47
|
| Rate for Payer: Frontpath All Commercial |
$1.47
|
| Rate for Payer: Humana ChoiceCare |
$1.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.44
|
| Rate for Payer: PHCS All Commercial |
$1.20
|
| Rate for Payer: PHP All Commercial |
$1.21
|
| Rate for Payer: Sagamore Health Network All Products |
$1.23
|
| Rate for Payer: Signature Care EPO |
$1.32
|
| Rate for Payer: Signature Care PPO |
$1.40
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
|
|
SILVER SULFADIAZINE 1 % TOP CREA
|
Facility
OP
|
$341.60
|
|
|
Service Code
|
NDC 43598021040
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.73 |
| Max. Negotiated Rate |
$317.69 |
| Rate for Payer: Aetna Commercial |
$288.31
|
| Rate for Payer: Aetna Medicare |
$112.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$112.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$196.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$213.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$129.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$124.00
|
| Rate for Payer: Cash Price |
$211.79
|
| Rate for Payer: Centivo All Commercial |
$174.22
|
| Rate for Payer: Cigna All Commercial |
$294.80
|
| Rate for Payer: CORVEL All Commercial |
$317.69
|
| Rate for Payer: Coventry All Commercial |
$300.61
|
| Rate for Payer: Encore All Commercial |
$314.44
|
| Rate for Payer: Frontpath All Commercial |
$314.27
|
| Rate for Payer: Humana ChoiceCare |
$295.04
|
| Rate for Payer: Humana Medicare |
$174.22
|
| Rate for Payer: Lucent All Commercial |
$174.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.44
|
| Rate for Payer: PHCS All Commercial |
$256.20
|
| Rate for Payer: PHP All Commercial |
$259.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$133.22
|
| Rate for Payer: Sagamore Health Network All Products |
$263.72
|
| Rate for Payer: Signature Care EPO |
$283.53
|
| Rate for Payer: Signature Care PPO |
$300.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$290.36
|
| Rate for Payer: United Healthcare Commercial |
$269.18
|
| Rate for Payer: United Healthcare Medicare |
$112.73
|
|
|
SILVER SULFADIAZINE 1 % TOP CREA
|
Facility
IP
|
$341.60
|
|
|
Service Code
|
NDC 43598021040
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$256.20 |
| Max. Negotiated Rate |
$317.69 |
| Rate for Payer: Aetna Commercial |
$295.14
|
| Rate for Payer: Cash Price |
$211.79
|
| Rate for Payer: Cigna All Commercial |
$294.80
|
| Rate for Payer: CORVEL All Commercial |
$317.69
|
| Rate for Payer: Coventry All Commercial |
$300.61
|
| Rate for Payer: Encore All Commercial |
$314.44
|
| Rate for Payer: Frontpath All Commercial |
$314.27
|
| Rate for Payer: Humana ChoiceCare |
$295.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.44
|
| Rate for Payer: PHCS All Commercial |
$256.20
|
| Rate for Payer: PHP All Commercial |
$259.07
|
| Rate for Payer: Sagamore Health Network All Products |
$263.72
|
| Rate for Payer: Signature Care EPO |
$283.53
|
| Rate for Payer: Signature Care PPO |
$300.61
|
| Rate for Payer: United Healthcare Commercial |
$269.18
|
|
|
SILVER SULFADIAZINE 1 % TOP CREA
|
Facility
IP
|
$25.90
|
|
|
Service Code
|
NDC 67877012450
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.42 |
| Max. Negotiated Rate |
$24.09 |
| Rate for Payer: Aetna Commercial |
$22.38
|
| Rate for Payer: Cash Price |
$16.06
|
| Rate for Payer: Cigna All Commercial |
$22.35
|
| Rate for Payer: CORVEL All Commercial |
$24.09
|
| Rate for Payer: Coventry All Commercial |
$22.79
|
| Rate for Payer: Encore All Commercial |
$23.84
|
| Rate for Payer: Frontpath All Commercial |
$23.83
|
| Rate for Payer: Humana ChoiceCare |
$22.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.31
|
| Rate for Payer: PHCS All Commercial |
$19.42
|
| Rate for Payer: PHP All Commercial |
$19.64
|
| Rate for Payer: Sagamore Health Network All Products |
$19.99
|
| Rate for Payer: Signature Care EPO |
$21.50
|
| Rate for Payer: Signature Care PPO |
$22.79
|
| Rate for Payer: United Healthcare Commercial |
$20.41
|
|
|
SILVER SULFADIAZINE 1 % TOP CREA
|
Facility
OP
|
$25.90
|
|
|
Service Code
|
NDC 67877012450
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.55 |
| Max. Negotiated Rate |
$24.09 |
| Rate for Payer: Aetna Commercial |
$21.86
|
| Rate for Payer: Aetna Medicare |
$8.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.40
|
| Rate for Payer: Cash Price |
$16.06
|
| Rate for Payer: Centivo All Commercial |
$13.21
|
| Rate for Payer: Cigna All Commercial |
$22.35
|
| Rate for Payer: CORVEL All Commercial |
$24.09
|
| Rate for Payer: Coventry All Commercial |
$22.79
|
| Rate for Payer: Encore All Commercial |
$23.84
|
| Rate for Payer: Frontpath All Commercial |
$23.83
|
| Rate for Payer: Humana ChoiceCare |
$22.37
|
| Rate for Payer: Humana Medicare |
$13.21
|
| Rate for Payer: Lucent All Commercial |
$13.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.31
|
| Rate for Payer: PHCS All Commercial |
$19.42
|
| Rate for Payer: PHP All Commercial |
$19.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.10
|
| Rate for Payer: Sagamore Health Network All Products |
$19.99
|
| Rate for Payer: Signature Care EPO |
$21.50
|
| Rate for Payer: Signature Care PPO |
$22.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22.02
|
| Rate for Payer: United Healthcare Commercial |
$20.41
|
| Rate for Payer: United Healthcare Medicare |
$8.55
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DRPS
|
Facility
OP
|
$32.24
|
|
|
Service Code
|
NDC 19903001021
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.64 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$27.21
|
| Rate for Payer: Aetna Medicare |
$10.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$18.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.15
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.70
|
| Rate for Payer: Cash Price |
$19.99
|
| Rate for Payer: Cash Price |
$19.99
|
| Rate for Payer: Centivo All Commercial |
$16.44
|
| Rate for Payer: Cigna All Commercial |
$27.82
|
| Rate for Payer: CORVEL All Commercial |
$29.98
|
| Rate for Payer: Coventry All Commercial |
$28.37
|
| Rate for Payer: Encore All Commercial |
$29.67
|
| Rate for Payer: Frontpath All Commercial |
$29.66
|
| Rate for Payer: Humana ChoiceCare |
$27.84
|
| Rate for Payer: Humana Medicare |
$16.44
|
| Rate for Payer: Lucent All Commercial |
$16.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.01
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$24.18
|
| Rate for Payer: PHP All Commercial |
$24.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.57
|
| Rate for Payer: Sagamore Health Network All Products |
$24.89
|
| Rate for Payer: Signature Care EPO |
$26.76
|
| Rate for Payer: Signature Care PPO |
$28.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27.40
|
| Rate for Payer: United Healthcare Commercial |
$25.40
|
| Rate for Payer: United Healthcare Medicare |
$10.64
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DRPS
|
Facility
IP
|
$32.24
|
|
|
Service Code
|
NDC 19903001021
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$29.98 |
| Rate for Payer: Aetna Commercial |
$27.85
|
| Rate for Payer: Cash Price |
$19.99
|
| Rate for Payer: Cigna All Commercial |
$27.82
|
| Rate for Payer: CORVEL All Commercial |
$29.98
|
| Rate for Payer: Coventry All Commercial |
$28.37
|
| Rate for Payer: Encore All Commercial |
$29.67
|
| Rate for Payer: Frontpath All Commercial |
$29.66
|
| Rate for Payer: Humana ChoiceCare |
$27.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.01
|
| Rate for Payer: PHCS All Commercial |
$24.18
|
| Rate for Payer: PHP All Commercial |
$24.45
|
| Rate for Payer: Sagamore Health Network All Products |
$24.89
|
| Rate for Payer: Signature Care EPO |
$26.76
|
| Rate for Payer: Signature Care PPO |
$28.37
|
| Rate for Payer: United Healthcare Commercial |
$25.40
|
|
|
SIMETHICONE 80 MG ORAL CHEW
|
Facility
IP
|
$1.11
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna Commercial |
$0.96
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna All Commercial |
$0.96
|
| Rate for Payer: CORVEL All Commercial |
$1.04
|
| Rate for Payer: Coventry All Commercial |
$0.98
|
| Rate for Payer: Encore All Commercial |
$1.02
|
| Rate for Payer: Frontpath All Commercial |
$1.02
|
| Rate for Payer: Humana ChoiceCare |
$0.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.00
|
| Rate for Payer: PHCS All Commercial |
$0.83
|
| Rate for Payer: PHP All Commercial |
$0.84
|
| Rate for Payer: Sagamore Health Network All Products |
$0.86
|
| Rate for Payer: Signature Care EPO |
$0.92
|
| Rate for Payer: Signature Care PPO |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$0.88
|
|
|
SIMETHICONE 80 MG ORAL CHEW
|
Facility
OP
|
$1.11
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Aetna Commercial |
$0.94
|
| Rate for Payer: Aetna Medicare |
$0.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.40
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Centivo All Commercial |
$0.57
|
| Rate for Payer: Cigna All Commercial |
$0.96
|
| Rate for Payer: CORVEL All Commercial |
$1.04
|
| Rate for Payer: Coventry All Commercial |
$0.98
|
| Rate for Payer: Encore All Commercial |
$1.02
|
| Rate for Payer: Frontpath All Commercial |
$1.02
|
| Rate for Payer: Humana ChoiceCare |
$0.96
|
| Rate for Payer: Humana Medicare |
$0.57
|
| Rate for Payer: Lucent All Commercial |
$0.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.00
|
| Rate for Payer: PHCS All Commercial |
$0.83
|
| Rate for Payer: PHP All Commercial |
$0.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.43
|
| Rate for Payer: Sagamore Health Network All Products |
$0.86
|
| Rate for Payer: Signature Care EPO |
$0.92
|
| Rate for Payer: Signature Care PPO |
$0.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$0.88
|
| Rate for Payer: United Healthcare Medicare |
$0.37
|
|
|
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm
|
Facility
OP
|
$648.18
|
|
|
Service Code
|
CPT 12002
|
| Hospital Charge Code |
CPT-12002
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$648.18 |
| Max. Negotiated Rate |
$648.18 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$648.18
|
| Rate for Payer: Managed Health Services Medicaid |
$648.18
|
| Rate for Payer: MDWise Medicaid |
$648.18
|
|
|
SINCALIDE 5 MCG INJ SOLR
|
Facility
IP
|
$618.72
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
11368
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$464.04 |
| Max. Negotiated Rate |
$575.41 |
| Rate for Payer: Aetna Commercial |
$534.57
|
| Rate for Payer: Cash Price |
$383.61
|
| Rate for Payer: Cigna All Commercial |
$533.96
|
| Rate for Payer: CORVEL All Commercial |
$575.41
|
| Rate for Payer: Coventry All Commercial |
$544.47
|
| Rate for Payer: Encore All Commercial |
$569.53
|
| Rate for Payer: Frontpath All Commercial |
$569.22
|
| Rate for Payer: Humana ChoiceCare |
$534.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$556.85
|
| Rate for Payer: PHCS All Commercial |
$464.04
|
| Rate for Payer: PHP All Commercial |
$469.24
|
| Rate for Payer: Sagamore Health Network All Products |
$477.65
|
| Rate for Payer: Signature Care EPO |
$513.54
|
| Rate for Payer: Signature Care PPO |
$544.47
|
| Rate for Payer: United Healthcare Commercial |
$487.55
|
|
|
SINCALIDE 5 MCG INJ SOLR
|
Facility
OP
|
$618.72
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
11368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$204.18 |
| Max. Negotiated Rate |
$575.41 |
| Rate for Payer: Aetna Commercial |
$522.20
|
| Rate for Payer: Aetna Medicare |
$204.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$204.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$355.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$386.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$234.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$224.60
|
| Rate for Payer: Cash Price |
$383.61
|
| Rate for Payer: Centivo All Commercial |
$315.55
|
| Rate for Payer: Cigna All Commercial |
$533.96
|
| Rate for Payer: CORVEL All Commercial |
$575.41
|
| Rate for Payer: Coventry All Commercial |
$544.47
|
| Rate for Payer: Encore All Commercial |
$569.53
|
| Rate for Payer: Frontpath All Commercial |
$569.22
|
| Rate for Payer: Humana ChoiceCare |
$534.39
|
| Rate for Payer: Humana Medicare |
$315.55
|
| Rate for Payer: Lucent All Commercial |
$315.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$556.85
|
| Rate for Payer: PHCS All Commercial |
$464.04
|
| Rate for Payer: PHP All Commercial |
$469.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$241.30
|
| Rate for Payer: Sagamore Health Network All Products |
$477.65
|
| Rate for Payer: Signature Care EPO |
$513.54
|
| Rate for Payer: Signature Care PPO |
$544.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$525.91
|
| Rate for Payer: United Healthcare Commercial |
$487.55
|
| Rate for Payer: United Healthcare Medicare |
$204.18
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG ORAL TAB
|
Facility
IP
|
$126.81
|
|
|
Service Code
|
NDC 00006027731
|
| Hospital Charge Code |
77617
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$95.10 |
| Max. Negotiated Rate |
$117.93 |
| Rate for Payer: Aetna Commercial |
$109.56
|
| Rate for Payer: Cash Price |
$78.62
|
| Rate for Payer: Cigna All Commercial |
$109.43
|
| Rate for Payer: CORVEL All Commercial |
$117.93
|
| Rate for Payer: Coventry All Commercial |
$111.59
|
| Rate for Payer: Encore All Commercial |
$116.72
|
| Rate for Payer: Frontpath All Commercial |
$116.66
|
| Rate for Payer: Humana ChoiceCare |
$109.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$114.12
|
| Rate for Payer: PHCS All Commercial |
$95.10
|
| Rate for Payer: PHP All Commercial |
$96.17
|
| Rate for Payer: Sagamore Health Network All Products |
$97.89
|
| Rate for Payer: Signature Care EPO |
$105.25
|
| Rate for Payer: Signature Care PPO |
$111.59
|
| Rate for Payer: United Healthcare Commercial |
$99.92
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG ORAL TAB
|
Facility
OP
|
$126.81
|
|
|
Service Code
|
NDC 00006027731
|
| Hospital Charge Code |
77617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.85 |
| Max. Negotiated Rate |
$117.93 |
| Rate for Payer: Aetna Commercial |
$107.02
|
| Rate for Payer: Aetna Medicare |
$41.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$41.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$72.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$79.27
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$48.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$46.03
|
| Rate for Payer: Cash Price |
$78.62
|
| Rate for Payer: Centivo All Commercial |
$64.67
|
| Rate for Payer: Cigna All Commercial |
$109.43
|
| Rate for Payer: CORVEL All Commercial |
$117.93
|
| Rate for Payer: Coventry All Commercial |
$111.59
|
| Rate for Payer: Encore All Commercial |
$116.72
|
| Rate for Payer: Frontpath All Commercial |
$116.66
|
| Rate for Payer: Humana ChoiceCare |
$109.52
|
| Rate for Payer: Humana Medicare |
$64.67
|
| Rate for Payer: Lucent All Commercial |
$64.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$114.12
|
| Rate for Payer: PHCS All Commercial |
$95.10
|
| Rate for Payer: PHP All Commercial |
$96.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$49.45
|
| Rate for Payer: Sagamore Health Network All Products |
$97.89
|
| Rate for Payer: Signature Care EPO |
$105.25
|
| Rate for Payer: Signature Care PPO |
$111.59
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$107.78
|
| Rate for Payer: United Healthcare Commercial |
$99.92
|
| Rate for Payer: United Healthcare Medicare |
$41.85
|
|
|
SOD BICARB-CITRIC AC-SIMETH 2.21-1.53 GRAM/4 GRAM ORAL GREP
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
NDC 10361079301
|
| Hospital Charge Code |
159143
|
|
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
|
|
|
SOD BICARB-CITRIC AC-SIMETH 2.21-1.53 GRAM/4 GRAM ORAL GREP
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
NDC 10361079301
|
| Hospital Charge Code |
159143
|
|
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
|
|
|
SOD BORATE-BORIC AC-NACL-WATER OPHT IRSL
|
Facility
IP
|
$23.95
|
|
|
Service Code
|
NDC 10119000252
|
| Hospital Charge Code |
163510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.97 |
| Max. Negotiated Rate |
$22.28 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Cigna All Commercial |
$20.67
|
| Rate for Payer: CORVEL All Commercial |
$22.28
|
| Rate for Payer: Coventry All Commercial |
$21.08
|
| Rate for Payer: Encore All Commercial |
$22.05
|
| Rate for Payer: Frontpath All Commercial |
$22.04
|
| Rate for Payer: Humana ChoiceCare |
$20.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.56
|
| Rate for Payer: PHCS All Commercial |
$17.97
|
| Rate for Payer: PHP All Commercial |
$18.17
|
| Rate for Payer: Sagamore Health Network All Products |
$18.49
|
| Rate for Payer: Signature Care EPO |
$19.88
|
| Rate for Payer: Signature Care PPO |
$21.08
|
| Rate for Payer: United Healthcare Commercial |
$18.88
|
|
|
SOD BORATE-BORIC AC-NACL-WATER OPHT IRSL
|
Facility
OP
|
$23.95
|
|
|
Service Code
|
NDC 10119000252
|
| Hospital Charge Code |
163510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.90 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$20.22
|
| Rate for Payer: Aetna Medicare |
$7.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$13.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14.97
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.70
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Cash Price |
$14.85
|
| Rate for Payer: Centivo All Commercial |
$12.22
|
| Rate for Payer: Cigna All Commercial |
$20.67
|
| Rate for Payer: CORVEL All Commercial |
$22.28
|
| Rate for Payer: Coventry All Commercial |
$21.08
|
| Rate for Payer: Encore All Commercial |
$22.05
|
| Rate for Payer: Frontpath All Commercial |
$22.04
|
| Rate for Payer: Humana ChoiceCare |
$20.69
|
| Rate for Payer: Humana Medicare |
$12.22
|
| Rate for Payer: Lucent All Commercial |
$12.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.56
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$17.97
|
| Rate for Payer: PHP All Commercial |
$18.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.34
|
| Rate for Payer: Sagamore Health Network All Products |
$18.49
|
| Rate for Payer: Signature Care EPO |
$19.88
|
| Rate for Payer: Signature Care PPO |
$21.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.36
|
| Rate for Payer: United Healthcare Commercial |
$18.88
|
| Rate for Payer: United Healthcare Medicare |
$7.90
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) IV SOLN
|
Facility
OP
|
$57.05
|
|
|
Service Code
|
NDC 00409662514
|
| Hospital Charge Code |
111015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.83 |
| Max. Negotiated Rate |
$53.06 |
| Rate for Payer: Aetna Commercial |
$48.15
|
| Rate for Payer: Aetna Medicare |
$18.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$32.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$35.66
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.71
|
| Rate for Payer: Cash Price |
$35.37
|
| Rate for Payer: Cash Price |
$35.37
|
| Rate for Payer: Centivo All Commercial |
$29.10
|
| Rate for Payer: Cigna All Commercial |
$49.23
|
| Rate for Payer: CORVEL All Commercial |
$53.06
|
| Rate for Payer: Coventry All Commercial |
$50.20
|
| Rate for Payer: Encore All Commercial |
$52.51
|
| Rate for Payer: Frontpath All Commercial |
$52.49
|
| Rate for Payer: Humana ChoiceCare |
$49.27
|
| Rate for Payer: Humana Medicare |
$29.10
|
| Rate for Payer: Lucent All Commercial |
$29.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.34
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$42.79
|
| Rate for Payer: PHP All Commercial |
$43.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.25
|
| Rate for Payer: Sagamore Health Network All Products |
$44.04
|
| Rate for Payer: Signature Care EPO |
$47.35
|
| Rate for Payer: Signature Care PPO |
$50.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$48.49
|
| Rate for Payer: United Healthcare Commercial |
$44.96
|
| Rate for Payer: United Healthcare Medicare |
$18.83
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) IV SOLN
|
Facility
IP
|
$57.05
|
|
|
Service Code
|
NDC 00409662514
|
| Hospital Charge Code |
111015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.79 |
| Max. Negotiated Rate |
$53.06 |
| Rate for Payer: Aetna Commercial |
$49.29
|
| Rate for Payer: Cash Price |
$35.37
|
| Rate for Payer: Cigna All Commercial |
$49.23
|
| Rate for Payer: CORVEL All Commercial |
$53.06
|
| Rate for Payer: Coventry All Commercial |
$50.20
|
| Rate for Payer: Encore All Commercial |
$52.51
|
| Rate for Payer: Frontpath All Commercial |
$52.49
|
| Rate for Payer: Humana ChoiceCare |
$49.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.34
|
| Rate for Payer: PHCS All Commercial |
$42.79
|
| Rate for Payer: PHP All Commercial |
$43.27
|
| Rate for Payer: Sagamore Health Network All Products |
$44.04
|
| Rate for Payer: Signature Care EPO |
$47.35
|
| Rate for Payer: Signature Care PPO |
$50.20
|
| Rate for Payer: United Healthcare Commercial |
$44.96
|
|
|
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) IV SYRG
|
Facility
OP
|
$108.50
|
|
|
Service Code
|
NDC 00409553414
|
| Hospital Charge Code |
7306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.80 |
| Max. Negotiated Rate |
$100.90 |
| Rate for Payer: Aetna Commercial |
$91.57
|
| Rate for Payer: Aetna Medicare |
$35.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$62.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$67.82
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.39
|
| Rate for Payer: Cash Price |
$67.27
|
| Rate for Payer: Cash Price |
$67.27
|
| Rate for Payer: Centivo All Commercial |
$55.34
|
| Rate for Payer: Cigna All Commercial |
$93.64
|
| Rate for Payer: CORVEL All Commercial |
$100.90
|
| Rate for Payer: Coventry All Commercial |
$95.48
|
| Rate for Payer: Encore All Commercial |
$99.87
|
| Rate for Payer: Frontpath All Commercial |
$99.82
|
| Rate for Payer: Humana ChoiceCare |
$93.71
|
| Rate for Payer: Humana Medicare |
$55.34
|
| Rate for Payer: Lucent All Commercial |
$55.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.65
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$81.38
|
| Rate for Payer: PHP All Commercial |
$82.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$42.32
|
| Rate for Payer: Sagamore Health Network All Products |
$83.76
|
| Rate for Payer: Signature Care EPO |
$90.06
|
| Rate for Payer: Signature Care PPO |
$95.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$92.22
|
| Rate for Payer: United Healthcare Commercial |
$85.50
|
| Rate for Payer: United Healthcare Medicare |
$35.80
|
|
|
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) IV SYRG
|
Facility
IP
|
$108.50
|
|
|
Service Code
|
NDC 00409553414
|
| Hospital Charge Code |
7306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.38 |
| Max. Negotiated Rate |
$100.90 |
| Rate for Payer: Aetna Commercial |
$93.74
|
| Rate for Payer: Cash Price |
$67.27
|
| Rate for Payer: Cigna All Commercial |
$93.64
|
| Rate for Payer: CORVEL All Commercial |
$100.90
|
| Rate for Payer: Coventry All Commercial |
$95.48
|
| Rate for Payer: Encore All Commercial |
$99.87
|
| Rate for Payer: Frontpath All Commercial |
$99.82
|
| Rate for Payer: Humana ChoiceCare |
$93.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.65
|
| Rate for Payer: PHCS All Commercial |
$81.38
|
| Rate for Payer: PHP All Commercial |
$82.29
|
| Rate for Payer: Sagamore Health Network All Products |
$83.76
|
| Rate for Payer: Signature Care EPO |
$90.06
|
| Rate for Payer: Signature Care PPO |
$95.48
|
| Rate for Payer: United Healthcare Commercial |
$85.50
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
OP
|
$156.17
|
|
|
Service Code
|
NDC 63323008305
|
| Hospital Charge Code |
111085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$145.24 |
| Rate for Payer: Aetna Commercial |
$131.81
|
| Rate for Payer: Aetna Medicare |
$51.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$51.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$89.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$97.62
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$59.27
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$56.69
|
| Rate for Payer: Cash Price |
$96.83
|
| Rate for Payer: Cash Price |
$96.83
|
| Rate for Payer: Centivo All Commercial |
$79.65
|
| Rate for Payer: Cigna All Commercial |
$134.77
|
| Rate for Payer: CORVEL All Commercial |
$145.24
|
| Rate for Payer: Coventry All Commercial |
$137.43
|
| Rate for Payer: Encore All Commercial |
$143.75
|
| Rate for Payer: Frontpath All Commercial |
$143.68
|
| Rate for Payer: Humana ChoiceCare |
$134.88
|
| Rate for Payer: Humana Medicare |
$79.65
|
| Rate for Payer: Lucent All Commercial |
$79.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$140.55
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$117.13
|
| Rate for Payer: PHP All Commercial |
$118.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$60.91
|
| Rate for Payer: Sagamore Health Network All Products |
$120.56
|
| Rate for Payer: Signature Care EPO |
$129.62
|
| Rate for Payer: Signature Care PPO |
$137.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$132.74
|
| Rate for Payer: United Healthcare Commercial |
$123.06
|
| Rate for Payer: United Healthcare Medicare |
$51.54
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
IP
|
$156.17
|
|
|
Service Code
|
NDC 63323008305
|
| Hospital Charge Code |
111085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.13 |
| Max. Negotiated Rate |
$145.24 |
| Rate for Payer: Aetna Commercial |
$134.93
|
| Rate for Payer: Cash Price |
$96.83
|
| Rate for Payer: Cigna All Commercial |
$134.77
|
| Rate for Payer: CORVEL All Commercial |
$145.24
|
| Rate for Payer: Coventry All Commercial |
$137.43
|
| Rate for Payer: Encore All Commercial |
$143.75
|
| Rate for Payer: Frontpath All Commercial |
$143.68
|
| Rate for Payer: Humana ChoiceCare |
$134.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$140.55
|
| Rate for Payer: PHCS All Commercial |
$117.13
|
| Rate for Payer: PHP All Commercial |
$118.44
|
| Rate for Payer: Sagamore Health Network All Products |
$120.56
|
| Rate for Payer: Signature Care EPO |
$129.62
|
| Rate for Payer: Signature Care PPO |
$137.43
|
| Rate for Payer: United Healthcare Commercial |
$123.06
|
|
