|
SODIUM BICARBONATE 4.2 % IV SOLN S.O. (CAMERON)
|
Facility
OP
|
$63.21
|
|
|
Service Code
|
NDC 51754501201
|
| Hospital Charge Code |
140111085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.86 |
| Max. Negotiated Rate |
$58.79 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Medicare |
$20.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$20.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$36.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.51
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.95
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Centivo All Commercial |
$32.24
|
| Rate for Payer: Cigna All Commercial |
$54.55
|
| Rate for Payer: CORVEL All Commercial |
$58.79
|
| Rate for Payer: Coventry All Commercial |
$55.62
|
| Rate for Payer: Encore All Commercial |
$58.18
|
| Rate for Payer: Frontpath All Commercial |
$58.15
|
| Rate for Payer: Humana ChoiceCare |
$54.59
|
| Rate for Payer: Humana Medicare |
$32.24
|
| Rate for Payer: Lucent All Commercial |
$32.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.89
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$47.41
|
| Rate for Payer: PHP All Commercial |
$47.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.65
|
| Rate for Payer: Sagamore Health Network All Products |
$48.80
|
| Rate for Payer: Signature Care EPO |
$52.46
|
| Rate for Payer: Signature Care PPO |
$55.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$53.73
|
| Rate for Payer: United Healthcare Commercial |
$49.81
|
| Rate for Payer: United Healthcare Medicare |
$20.86
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN S.O. (CAMERON)
|
Facility
OP
|
$63.21
|
|
|
Service Code
|
NDC 51754501204
|
| Hospital Charge Code |
140111085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.86 |
| Max. Negotiated Rate |
$58.79 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Medicare |
$20.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$20.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$36.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.51
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.95
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Centivo All Commercial |
$32.24
|
| Rate for Payer: Cigna All Commercial |
$54.55
|
| Rate for Payer: CORVEL All Commercial |
$58.79
|
| Rate for Payer: Coventry All Commercial |
$55.62
|
| Rate for Payer: Encore All Commercial |
$58.18
|
| Rate for Payer: Frontpath All Commercial |
$58.15
|
| Rate for Payer: Humana ChoiceCare |
$54.59
|
| Rate for Payer: Humana Medicare |
$32.24
|
| Rate for Payer: Lucent All Commercial |
$32.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.89
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$47.41
|
| Rate for Payer: PHP All Commercial |
$47.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.65
|
| Rate for Payer: Sagamore Health Network All Products |
$48.80
|
| Rate for Payer: Signature Care EPO |
$52.46
|
| Rate for Payer: Signature Care PPO |
$55.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$53.73
|
| Rate for Payer: United Healthcare Commercial |
$49.81
|
| Rate for Payer: United Healthcare Medicare |
$20.86
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN S.O. (CAMERON)
|
Facility
IP
|
$63.21
|
|
|
Service Code
|
NDC 51754501204
|
| Hospital Charge Code |
140111085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.41 |
| Max. Negotiated Rate |
$58.79 |
| Rate for Payer: Aetna Commercial |
$54.61
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna All Commercial |
$54.55
|
| Rate for Payer: CORVEL All Commercial |
$58.79
|
| Rate for Payer: Coventry All Commercial |
$55.62
|
| Rate for Payer: Encore All Commercial |
$58.18
|
| Rate for Payer: Frontpath All Commercial |
$58.15
|
| Rate for Payer: Humana ChoiceCare |
$54.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.89
|
| Rate for Payer: PHCS All Commercial |
$47.41
|
| Rate for Payer: PHP All Commercial |
$47.94
|
| Rate for Payer: Sagamore Health Network All Products |
$48.80
|
| Rate for Payer: Signature Care EPO |
$52.46
|
| Rate for Payer: Signature Care PPO |
$55.62
|
| Rate for Payer: United Healthcare Commercial |
$49.81
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN S.O. (CAMERON)
|
Facility
IP
|
$63.21
|
|
|
Service Code
|
NDC 51754501201
|
| Hospital Charge Code |
140111085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.41 |
| Max. Negotiated Rate |
$58.79 |
| Rate for Payer: Aetna Commercial |
$54.61
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna All Commercial |
$54.55
|
| Rate for Payer: CORVEL All Commercial |
$58.79
|
| Rate for Payer: Coventry All Commercial |
$55.62
|
| Rate for Payer: Encore All Commercial |
$58.18
|
| Rate for Payer: Frontpath All Commercial |
$58.15
|
| Rate for Payer: Humana ChoiceCare |
$54.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.89
|
| Rate for Payer: PHCS All Commercial |
$47.41
|
| Rate for Payer: PHP All Commercial |
$47.94
|
| Rate for Payer: Sagamore Health Network All Products |
$48.80
|
| Rate for Payer: Signature Care EPO |
$52.46
|
| Rate for Payer: Signature Care PPO |
$55.62
|
| Rate for Payer: United Healthcare Commercial |
$49.81
|
|
|
SODIUM BICARBONATE 650 MG ORAL TAB
|
Facility
IP
|
$0.97
|
|
|
Service Code
|
NDC 00904726161
|
| Hospital Charge Code |
7312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna Commercial |
$0.83
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.83
|
| Rate for Payer: CORVEL All Commercial |
$0.90
|
| Rate for Payer: Coventry All Commercial |
$0.85
|
| Rate for Payer: Encore All Commercial |
$0.89
|
| Rate for Payer: Frontpath All Commercial |
$0.89
|
| Rate for Payer: Humana ChoiceCare |
$0.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.87
|
| Rate for Payer: PHCS All Commercial |
$0.72
|
| Rate for Payer: PHP All Commercial |
$0.73
|
| Rate for Payer: Sagamore Health Network All Products |
$0.75
|
| Rate for Payer: Signature Care EPO |
$0.80
|
| Rate for Payer: Signature Care PPO |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.76
|
|
|
SODIUM BICARBONATE 650 MG ORAL TAB
|
Facility
OP
|
$0.97
|
|
|
Service Code
|
NDC 00904726161
|
| Hospital Charge Code |
7312
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna Commercial |
$0.82
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.49
|
| Rate for Payer: Cigna All Commercial |
$0.83
|
| Rate for Payer: CORVEL All Commercial |
$0.90
|
| Rate for Payer: Coventry All Commercial |
$0.85
|
| Rate for Payer: Encore All Commercial |
$0.89
|
| Rate for Payer: Frontpath All Commercial |
$0.89
|
| Rate for Payer: Humana ChoiceCare |
$0.83
|
| Rate for Payer: Humana Medicare |
$0.49
|
| Rate for Payer: Lucent All Commercial |
$0.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.87
|
| Rate for Payer: PHCS All Commercial |
$0.72
|
| Rate for Payer: PHP All Commercial |
$0.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.38
|
| Rate for Payer: Sagamore Health Network All Products |
$0.75
|
| Rate for Payer: Signature Care EPO |
$0.80
|
| Rate for Payer: Signature Care PPO |
$0.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$0.76
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRG
|
Facility
IP
|
$107.80
|
|
|
Service Code
|
NDC 76329335201
|
| Hospital Charge Code |
7309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.85 |
| Max. Negotiated Rate |
$100.25 |
| Rate for Payer: Aetna Commercial |
$93.14
|
| Rate for Payer: Cash Price |
$66.84
|
| Rate for Payer: Cigna All Commercial |
$93.03
|
| Rate for Payer: CORVEL All Commercial |
$100.25
|
| Rate for Payer: Coventry All Commercial |
$94.86
|
| Rate for Payer: Encore All Commercial |
$99.23
|
| Rate for Payer: Frontpath All Commercial |
$99.18
|
| Rate for Payer: Humana ChoiceCare |
$93.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.02
|
| Rate for Payer: PHCS All Commercial |
$80.85
|
| Rate for Payer: PHP All Commercial |
$81.76
|
| Rate for Payer: Sagamore Health Network All Products |
$83.22
|
| Rate for Payer: Signature Care EPO |
$89.47
|
| Rate for Payer: Signature Care PPO |
$94.86
|
| Rate for Payer: United Healthcare Commercial |
$84.95
|
|
|
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRG
|
Facility
OP
|
$107.80
|
|
|
Service Code
|
NDC 76329335201
|
| Hospital Charge Code |
7309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.57 |
| Max. Negotiated Rate |
$100.25 |
| Rate for Payer: Aetna Commercial |
$90.98
|
| Rate for Payer: Aetna Medicare |
$35.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$61.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$67.39
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.13
|
| Rate for Payer: Cash Price |
$66.84
|
| Rate for Payer: Cash Price |
$66.84
|
| Rate for Payer: Centivo All Commercial |
$54.98
|
| Rate for Payer: Cigna All Commercial |
$93.03
|
| Rate for Payer: CORVEL All Commercial |
$100.25
|
| Rate for Payer: Coventry All Commercial |
$94.86
|
| Rate for Payer: Encore All Commercial |
$99.23
|
| Rate for Payer: Frontpath All Commercial |
$99.18
|
| Rate for Payer: Humana ChoiceCare |
$93.11
|
| Rate for Payer: Humana Medicare |
$54.98
|
| Rate for Payer: Lucent All Commercial |
$54.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.02
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$80.85
|
| Rate for Payer: PHP All Commercial |
$81.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$42.04
|
| Rate for Payer: Sagamore Health Network All Products |
$83.22
|
| Rate for Payer: Signature Care EPO |
$89.47
|
| Rate for Payer: Signature Care PPO |
$94.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$91.63
|
| Rate for Payer: United Healthcare Commercial |
$84.95
|
| Rate for Payer: United Healthcare Medicare |
$35.57
|
|
|
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
7318
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.25
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Centivo All Commercial |
$21.42
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Humana Medicare |
$21.42
|
| Rate for Payer: Lucent All Commercial |
$21.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.86
|
|
|
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP
|
Facility
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
7318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
SODIUM CHLORIDE 0.45 % IV SOLP (IN ML/KG/HR)
|
Facility
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
158804
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
SODIUM CHLORIDE 0.45 % IV SOLP (IN ML/KG/HR)
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
158804
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.25
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Centivo All Commercial |
$21.42
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Humana Medicare |
$21.42
|
| Rate for Payer: Lucent All Commercial |
$21.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.86
|
|
|
SODIUM CHLORIDE 0.45% WITH KCL 20 MEQ/L IV SOLP
|
Facility
OP
|
$49.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
36046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.17 |
| Max. Negotiated Rate |
$45.57 |
| Rate for Payer: Aetna Commercial |
$41.36
|
| Rate for Payer: Aetna Medicare |
$16.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$28.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.79
|
| Rate for Payer: Cash Price |
$30.38
|
| Rate for Payer: Centivo All Commercial |
$24.99
|
| Rate for Payer: Cigna All Commercial |
$42.29
|
| Rate for Payer: CORVEL All Commercial |
$45.57
|
| Rate for Payer: Coventry All Commercial |
$43.12
|
| Rate for Payer: Encore All Commercial |
$45.10
|
| Rate for Payer: Frontpath All Commercial |
$45.08
|
| Rate for Payer: Humana ChoiceCare |
$42.32
|
| Rate for Payer: Humana Medicare |
$24.99
|
| Rate for Payer: Lucent All Commercial |
$24.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.10
|
| Rate for Payer: PHCS All Commercial |
$36.75
|
| Rate for Payer: PHP All Commercial |
$37.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.11
|
| Rate for Payer: Sagamore Health Network All Products |
$37.83
|
| Rate for Payer: Signature Care EPO |
$40.67
|
| Rate for Payer: Signature Care PPO |
$43.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.65
|
| Rate for Payer: United Healthcare Commercial |
$38.61
|
| Rate for Payer: United Healthcare Medicare |
$16.17
|
|
|
SODIUM CHLORIDE 0.45% WITH KCL 20 MEQ/L IV SOLP
|
Facility
IP
|
$49.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
36046
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$45.57 |
| Rate for Payer: Aetna Commercial |
$42.34
|
| Rate for Payer: Cash Price |
$30.38
|
| Rate for Payer: Cigna All Commercial |
$42.29
|
| Rate for Payer: CORVEL All Commercial |
$45.57
|
| Rate for Payer: Coventry All Commercial |
$43.12
|
| Rate for Payer: Encore All Commercial |
$45.10
|
| Rate for Payer: Frontpath All Commercial |
$45.08
|
| Rate for Payer: Humana ChoiceCare |
$42.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.10
|
| Rate for Payer: PHCS All Commercial |
$36.75
|
| Rate for Payer: PHP All Commercial |
$37.16
|
| Rate for Payer: Sagamore Health Network All Products |
$37.83
|
| Rate for Payer: Signature Care EPO |
$40.67
|
| Rate for Payer: Signature Care PPO |
$43.12
|
| Rate for Payer: United Healthcare Commercial |
$38.61
|
|
|
SODIUM CHLORIDE 0.65 % NASL SPRA
|
Facility
OP
|
$16.80
|
|
|
Service Code
|
NDC 56184012011
|
| Hospital Charge Code |
29676
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$15.62 |
| Rate for Payer: Aetna Commercial |
$14.18
|
| Rate for Payer: Aetna Medicare |
$5.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.10
|
| Rate for Payer: Cash Price |
$10.42
|
| Rate for Payer: Centivo All Commercial |
$8.57
|
| Rate for Payer: Cigna All Commercial |
$14.50
|
| Rate for Payer: CORVEL All Commercial |
$15.62
|
| Rate for Payer: Coventry All Commercial |
$14.78
|
| Rate for Payer: Encore All Commercial |
$15.46
|
| Rate for Payer: Frontpath All Commercial |
$15.46
|
| Rate for Payer: Humana ChoiceCare |
$14.51
|
| Rate for Payer: Humana Medicare |
$8.57
|
| Rate for Payer: Lucent All Commercial |
$8.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.12
|
| Rate for Payer: PHCS All Commercial |
$12.60
|
| Rate for Payer: PHP All Commercial |
$12.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.55
|
| Rate for Payer: Sagamore Health Network All Products |
$12.97
|
| Rate for Payer: Signature Care EPO |
$13.94
|
| Rate for Payer: Signature Care PPO |
$14.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$14.28
|
| Rate for Payer: United Healthcare Commercial |
$13.24
|
| Rate for Payer: United Healthcare Medicare |
$5.54
|
|
|
SODIUM CHLORIDE 0.65 % NASL SPRA
|
Facility
IP
|
$6.78
|
|
|
Service Code
|
NDC 00904386575
|
| Hospital Charge Code |
29676
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.08 |
| Max. Negotiated Rate |
$6.30 |
| Rate for Payer: Aetna Commercial |
$5.85
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cigna All Commercial |
$5.85
|
| Rate for Payer: CORVEL All Commercial |
$6.30
|
| Rate for Payer: Coventry All Commercial |
$5.96
|
| Rate for Payer: Encore All Commercial |
$6.24
|
| Rate for Payer: Frontpath All Commercial |
$6.23
|
| Rate for Payer: Humana ChoiceCare |
$5.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.10
|
| Rate for Payer: PHCS All Commercial |
$5.08
|
| Rate for Payer: PHP All Commercial |
$5.14
|
| Rate for Payer: Sagamore Health Network All Products |
$5.23
|
| Rate for Payer: Signature Care EPO |
$5.62
|
| Rate for Payer: Signature Care PPO |
$5.96
|
| Rate for Payer: United Healthcare Commercial |
$5.34
|
|
|
SODIUM CHLORIDE 0.65 % NASL SPRA
|
Facility
IP
|
$16.80
|
|
|
Service Code
|
NDC 56184012011
|
| Hospital Charge Code |
29676
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$15.62 |
| Rate for Payer: Aetna Commercial |
$14.52
|
| Rate for Payer: Cash Price |
$10.42
|
| Rate for Payer: Cigna All Commercial |
$14.50
|
| Rate for Payer: CORVEL All Commercial |
$15.62
|
| Rate for Payer: Coventry All Commercial |
$14.78
|
| Rate for Payer: Encore All Commercial |
$15.46
|
| Rate for Payer: Frontpath All Commercial |
$15.46
|
| Rate for Payer: Humana ChoiceCare |
$14.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.12
|
| Rate for Payer: PHCS All Commercial |
$12.60
|
| Rate for Payer: PHP All Commercial |
$12.74
|
| Rate for Payer: Sagamore Health Network All Products |
$12.97
|
| Rate for Payer: Signature Care EPO |
$13.94
|
| Rate for Payer: Signature Care PPO |
$14.78
|
| Rate for Payer: United Healthcare Commercial |
$13.24
|
|
|
SODIUM CHLORIDE 0.65 % NASL SPRA
|
Facility
OP
|
$6.78
|
|
|
Service Code
|
NDC 00904386575
|
| Hospital Charge Code |
29676
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$6.30 |
| Rate for Payer: Aetna Commercial |
$5.72
|
| Rate for Payer: Aetna Medicare |
$2.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.46
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Centivo All Commercial |
$3.46
|
| Rate for Payer: Cigna All Commercial |
$5.85
|
| Rate for Payer: CORVEL All Commercial |
$6.30
|
| Rate for Payer: Coventry All Commercial |
$5.96
|
| Rate for Payer: Encore All Commercial |
$6.24
|
| Rate for Payer: Frontpath All Commercial |
$6.23
|
| Rate for Payer: Humana ChoiceCare |
$5.85
|
| Rate for Payer: Humana Medicare |
$3.46
|
| Rate for Payer: Lucent All Commercial |
$3.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.10
|
| Rate for Payer: PHCS All Commercial |
$5.08
|
| Rate for Payer: PHP All Commercial |
$5.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.64
|
| Rate for Payer: Sagamore Health Network All Products |
$5.23
|
| Rate for Payer: Signature Care EPO |
$5.62
|
| Rate for Payer: Signature Care PPO |
$5.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.76
|
| Rate for Payer: United Healthcare Commercial |
$5.34
|
| Rate for Payer: United Healthcare Medicare |
$2.24
|
|
|
SODIUM CHLORIDE 0.9 % (FLUSH) INJ SYRG
|
Facility
IP
|
$2.73
|
|
|
Service Code
|
NDC 63807010010
|
| Hospital Charge Code |
7319
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Cigna All Commercial |
$2.36
|
| Rate for Payer: CORVEL All Commercial |
$2.54
|
| Rate for Payer: Coventry All Commercial |
$2.40
|
| Rate for Payer: Encore All Commercial |
$2.51
|
| Rate for Payer: Frontpath All Commercial |
$2.51
|
| Rate for Payer: Humana ChoiceCare |
$2.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.46
|
| Rate for Payer: PHCS All Commercial |
$2.05
|
| Rate for Payer: PHP All Commercial |
$2.07
|
| Rate for Payer: Sagamore Health Network All Products |
$2.11
|
| Rate for Payer: Signature Care EPO |
$2.27
|
| Rate for Payer: Signature Care PPO |
$2.40
|
| Rate for Payer: United Healthcare Commercial |
$2.15
|
|
|
SODIUM CHLORIDE 0.9 % (FLUSH) INJ SYRG
|
Facility
OP
|
$2.73
|
|
|
Service Code
|
NDC 63807010010
|
| Hospital Charge Code |
7319
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$2.30
|
| Rate for Payer: Aetna Medicare |
$0.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.71
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.99
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Centivo All Commercial |
$1.39
|
| Rate for Payer: Cigna All Commercial |
$2.36
|
| Rate for Payer: CORVEL All Commercial |
$2.54
|
| Rate for Payer: Coventry All Commercial |
$2.40
|
| Rate for Payer: Encore All Commercial |
$2.51
|
| Rate for Payer: Frontpath All Commercial |
$2.51
|
| Rate for Payer: Humana ChoiceCare |
$2.36
|
| Rate for Payer: Humana Medicare |
$1.39
|
| Rate for Payer: Lucent All Commercial |
$1.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.46
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$2.05
|
| Rate for Payer: PHP All Commercial |
$2.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.06
|
| Rate for Payer: Sagamore Health Network All Products |
$2.11
|
| Rate for Payer: Signature Care EPO |
$2.27
|
| Rate for Payer: Signature Care PPO |
$2.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.32
|
| Rate for Payer: United Healthcare Commercial |
$2.15
|
| Rate for Payer: United Healthcare Medicare |
$0.90
|
|
|
SODIUM CHLORIDE 0.9% FOR FLUSHING POST ALTEPLASE
|
Facility
OP
|
$29.75
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
800323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.82 |
| Max. Negotiated Rate |
$27.67 |
| Rate for Payer: Aetna Commercial |
$25.11
|
| Rate for Payer: Aetna Medicare |
$9.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$17.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.80
|
| Rate for Payer: Cash Price |
$18.45
|
| Rate for Payer: Centivo All Commercial |
$15.17
|
| Rate for Payer: Cigna All Commercial |
$25.67
|
| Rate for Payer: CORVEL All Commercial |
$27.67
|
| Rate for Payer: Coventry All Commercial |
$26.18
|
| Rate for Payer: Encore All Commercial |
$27.38
|
| Rate for Payer: Frontpath All Commercial |
$27.37
|
| Rate for Payer: Humana ChoiceCare |
$25.70
|
| Rate for Payer: Humana Medicare |
$15.17
|
| Rate for Payer: Lucent All Commercial |
$15.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.78
|
| Rate for Payer: PHCS All Commercial |
$22.31
|
| Rate for Payer: PHP All Commercial |
$22.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.60
|
| Rate for Payer: Sagamore Health Network All Products |
$22.97
|
| Rate for Payer: Signature Care EPO |
$24.69
|
| Rate for Payer: Signature Care PPO |
$26.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25.29
|
| Rate for Payer: United Healthcare Commercial |
$23.44
|
| Rate for Payer: United Healthcare Medicare |
$9.82
|
|
|
SODIUM CHLORIDE 0.9% FOR FLUSHING POST ALTEPLASE
|
Facility
IP
|
$29.75
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
800323
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$22.31 |
| Max. Negotiated Rate |
$27.67 |
| Rate for Payer: Aetna Commercial |
$25.70
|
| Rate for Payer: Cash Price |
$18.45
|
| Rate for Payer: Cigna All Commercial |
$25.67
|
| Rate for Payer: CORVEL All Commercial |
$27.67
|
| Rate for Payer: Coventry All Commercial |
$26.18
|
| Rate for Payer: Encore All Commercial |
$27.38
|
| Rate for Payer: Frontpath All Commercial |
$27.37
|
| Rate for Payer: Humana ChoiceCare |
$25.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.78
|
| Rate for Payer: PHCS All Commercial |
$22.31
|
| Rate for Payer: PHP All Commercial |
$22.56
|
| Rate for Payer: Sagamore Health Network All Products |
$22.97
|
| Rate for Payer: Signature Care EPO |
$24.69
|
| Rate for Payer: Signature Care PPO |
$26.18
|
| Rate for Payer: United Healthcare Commercial |
$23.44
|
|
|
SODIUM CHLORIDE 0.9% FOR LINE CARE - 250 ML BAG (CAMERON)
|
Facility
OP
|
$29.75
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
14010408027838
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.82 |
| Max. Negotiated Rate |
$27.67 |
| Rate for Payer: Aetna Commercial |
$25.11
|
| Rate for Payer: Aetna Medicare |
$9.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$17.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.80
|
| Rate for Payer: Cash Price |
$18.45
|
| Rate for Payer: Centivo All Commercial |
$15.17
|
| Rate for Payer: Cigna All Commercial |
$25.67
|
| Rate for Payer: CORVEL All Commercial |
$27.67
|
| Rate for Payer: Coventry All Commercial |
$26.18
|
| Rate for Payer: Encore All Commercial |
$27.38
|
| Rate for Payer: Frontpath All Commercial |
$27.37
|
| Rate for Payer: Humana ChoiceCare |
$25.70
|
| Rate for Payer: Humana Medicare |
$15.17
|
| Rate for Payer: Lucent All Commercial |
$15.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.78
|
| Rate for Payer: PHCS All Commercial |
$22.31
|
| Rate for Payer: PHP All Commercial |
$22.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.60
|
| Rate for Payer: Sagamore Health Network All Products |
$22.97
|
| Rate for Payer: Signature Care EPO |
$24.69
|
| Rate for Payer: Signature Care PPO |
$26.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25.29
|
| Rate for Payer: United Healthcare Commercial |
$23.44
|
| Rate for Payer: United Healthcare Medicare |
$9.82
|
|
|
SODIUM CHLORIDE 0.9% FOR LINE CARE - 250 ML BAG (CAMERON)
|
Facility
IP
|
$29.75
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
14010408027838
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$22.31 |
| Max. Negotiated Rate |
$27.67 |
| Rate for Payer: Aetna Commercial |
$25.70
|
| Rate for Payer: Cash Price |
$18.45
|
| Rate for Payer: Cigna All Commercial |
$25.67
|
| Rate for Payer: CORVEL All Commercial |
$27.67
|
| Rate for Payer: Coventry All Commercial |
$26.18
|
| Rate for Payer: Encore All Commercial |
$27.38
|
| Rate for Payer: Frontpath All Commercial |
$27.37
|
| Rate for Payer: Humana ChoiceCare |
$25.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.78
|
| Rate for Payer: PHCS All Commercial |
$22.31
|
| Rate for Payer: PHP All Commercial |
$22.56
|
| Rate for Payer: Sagamore Health Network All Products |
$22.97
|
| Rate for Payer: Signature Care EPO |
$24.69
|
| Rate for Payer: Signature Care PPO |
$26.18
|
| Rate for Payer: United Healthcare Commercial |
$23.44
|
|
|
SODIUM CHLORIDE 0.9 % INHL NEBU
|
Facility
IP
|
$1.41
|
|
|
Service Code
|
NDC 00487930133
|
| Hospital Charge Code |
7325
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Aetna Commercial |
$1.22
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna All Commercial |
$1.21
|
| Rate for Payer: CORVEL All Commercial |
$1.31
|
| Rate for Payer: Coventry All Commercial |
$1.24
|
| Rate for Payer: Encore All Commercial |
$1.30
|
| Rate for Payer: Frontpath All Commercial |
$1.29
|
| Rate for Payer: Humana ChoiceCare |
$1.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.27
|
| Rate for Payer: PHCS All Commercial |
$1.06
|
| Rate for Payer: PHP All Commercial |
$1.07
|
| Rate for Payer: Sagamore Health Network All Products |
$1.09
|
| Rate for Payer: Signature Care EPO |
$1.17
|
| Rate for Payer: Signature Care PPO |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.11
|
|
