|
SODIUM CHLORIDE 0.9 % INHL NEBU
|
Facility
OP
|
$1.41
|
|
|
Service Code
|
NDC 00487930133
|
| Hospital Charge Code |
7325
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$1.19
|
| Rate for Payer: Aetna Medicare |
$0.46
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.51
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Centivo All Commercial |
$0.72
|
| 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: Humana Medicare |
$0.72
|
| Rate for Payer: Lucent All Commercial |
$0.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.27
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$1.06
|
| Rate for Payer: PHP All Commercial |
$1.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.55
|
| 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: Three Rivers Preferred All Commercial |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$1.11
|
| Rate for Payer: United Healthcare Medicare |
$0.46
|
|
|
SODIUM CHLORIDE 0.9 % INJ SOLN
|
Facility
IP
|
$5.60
|
|
|
Service Code
|
NDC 00409488810
|
| Hospital Charge Code |
41463
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$5.21 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cigna All Commercial |
$4.83
|
| Rate for Payer: CORVEL All Commercial |
$5.21
|
| Rate for Payer: Coventry All Commercial |
$4.93
|
| Rate for Payer: Encore All Commercial |
$5.15
|
| Rate for Payer: Frontpath All Commercial |
$5.15
|
| Rate for Payer: Humana ChoiceCare |
$4.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.04
|
| Rate for Payer: PHCS All Commercial |
$4.20
|
| Rate for Payer: PHP All Commercial |
$4.25
|
| Rate for Payer: Sagamore Health Network All Products |
$4.32
|
| Rate for Payer: Signature Care EPO |
$4.65
|
| Rate for Payer: Signature Care PPO |
$4.93
|
| Rate for Payer: United Healthcare Commercial |
$4.41
|
|
|
SODIUM CHLORIDE 0.9 % INJ SOLN
|
Facility
IP
|
$6.51
|
|
|
Service Code
|
NDC 63323018610
|
| Hospital Charge Code |
41463
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.88 |
| Max. Negotiated Rate |
$6.05 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Cash Price |
$4.04
|
| Rate for Payer: Cigna All Commercial |
$5.62
|
| Rate for Payer: CORVEL All Commercial |
$6.05
|
| Rate for Payer: Coventry All Commercial |
$5.73
|
| Rate for Payer: Encore All Commercial |
$5.99
|
| Rate for Payer: Frontpath All Commercial |
$5.99
|
| Rate for Payer: Humana ChoiceCare |
$5.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.86
|
| Rate for Payer: PHCS All Commercial |
$4.88
|
| Rate for Payer: PHP All Commercial |
$4.94
|
| Rate for Payer: Sagamore Health Network All Products |
$5.03
|
| Rate for Payer: Signature Care EPO |
$5.40
|
| Rate for Payer: Signature Care PPO |
$5.73
|
| Rate for Payer: United Healthcare Commercial |
$5.13
|
|
|
SODIUM CHLORIDE 0.9 % INJ SOLN
|
Facility
OP
|
$6.51
|
|
|
Service Code
|
NDC 63323018610
|
| Hospital Charge Code |
41463
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$5.49
|
| Rate for Payer: Aetna Medicare |
$2.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.07
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.36
|
| Rate for Payer: Cash Price |
$4.04
|
| Rate for Payer: Cash Price |
$4.04
|
| Rate for Payer: Centivo All Commercial |
$3.32
|
| Rate for Payer: Cigna All Commercial |
$5.62
|
| Rate for Payer: CORVEL All Commercial |
$6.05
|
| Rate for Payer: Coventry All Commercial |
$5.73
|
| Rate for Payer: Encore All Commercial |
$5.99
|
| Rate for Payer: Frontpath All Commercial |
$5.99
|
| Rate for Payer: Humana ChoiceCare |
$5.62
|
| Rate for Payer: Humana Medicare |
$3.32
|
| Rate for Payer: Lucent All Commercial |
$3.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.86
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$4.88
|
| Rate for Payer: PHP All Commercial |
$4.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.54
|
| Rate for Payer: Sagamore Health Network All Products |
$5.03
|
| Rate for Payer: Signature Care EPO |
$5.40
|
| Rate for Payer: Signature Care PPO |
$5.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.53
|
| Rate for Payer: United Healthcare Commercial |
$5.13
|
| Rate for Payer: United Healthcare Medicare |
$2.15
|
|
|
SODIUM CHLORIDE 0.9 % INJ SOLN
|
Facility
OP
|
$5.60
|
|
|
Service Code
|
NDC 00409488810
|
| Hospital Charge Code |
41463
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$4.73
|
| Rate for Payer: Aetna Medicare |
$1.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.03
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Centivo All Commercial |
$2.86
|
| Rate for Payer: Cigna All Commercial |
$4.83
|
| Rate for Payer: CORVEL All Commercial |
$5.21
|
| Rate for Payer: Coventry All Commercial |
$4.93
|
| Rate for Payer: Encore All Commercial |
$5.15
|
| Rate for Payer: Frontpath All Commercial |
$5.15
|
| Rate for Payer: Humana ChoiceCare |
$4.84
|
| Rate for Payer: Humana Medicare |
$2.86
|
| Rate for Payer: Lucent All Commercial |
$2.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.04
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$4.20
|
| Rate for Payer: PHP All Commercial |
$4.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.18
|
| Rate for Payer: Sagamore Health Network All Products |
$4.32
|
| Rate for Payer: Signature Care EPO |
$4.65
|
| Rate for Payer: Signature Care PPO |
$4.93
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.76
|
| Rate for Payer: United Healthcare Commercial |
$4.41
|
| Rate for Payer: United Healthcare Medicare |
$1.85
|
|
|
SODIUM CHLORIDE 0.9% (IN ML/KG)
|
Facility
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
601103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$29.54
|
| Rate for Payer: Aetna Medicare |
$11.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.70
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Centivo All Commercial |
$17.85
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Humana Medicare |
$17.85
|
| Rate for Payer: Lucent All Commercial |
$17.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.75
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
| Rate for Payer: United Healthcare Medicare |
$11.55
|
|
|
SODIUM CHLORIDE 0.9% (IN ML/KG)
|
Facility
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
601103
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$30.24
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
|
|
SODIUM CHLORIDE 0.9% IRRIGATION (BOLUS)
|
Facility
OP
|
$47.25
|
|
|
Service Code
|
NDC 00338004802
|
| Hospital Charge Code |
408011403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.59 |
| Max. Negotiated Rate |
$43.94 |
| Rate for Payer: Aetna Commercial |
$39.88
|
| Rate for Payer: Aetna Medicare |
$15.59
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$27.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.15
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Centivo All Commercial |
$24.10
|
| Rate for Payer: Cigna All Commercial |
$40.78
|
| Rate for Payer: CORVEL All Commercial |
$43.94
|
| Rate for Payer: Coventry All Commercial |
$41.58
|
| Rate for Payer: Encore All Commercial |
$43.49
|
| Rate for Payer: Frontpath All Commercial |
$43.47
|
| Rate for Payer: Humana ChoiceCare |
$40.81
|
| Rate for Payer: Humana Medicare |
$24.10
|
| Rate for Payer: Lucent All Commercial |
$24.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.52
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$35.44
|
| Rate for Payer: PHP All Commercial |
$35.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.43
|
| Rate for Payer: Sagamore Health Network All Products |
$36.48
|
| Rate for Payer: Signature Care EPO |
$39.22
|
| Rate for Payer: Signature Care PPO |
$41.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.16
|
| Rate for Payer: United Healthcare Commercial |
$37.23
|
| Rate for Payer: United Healthcare Medicare |
$15.59
|
|
|
SODIUM CHLORIDE 0.9% IRRIGATION (BOLUS)
|
Facility
IP
|
$47.25
|
|
|
Service Code
|
NDC 00338004802
|
| Hospital Charge Code |
408011403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.44 |
| Max. Negotiated Rate |
$43.94 |
| Rate for Payer: Aetna Commercial |
$40.82
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cigna All Commercial |
$40.78
|
| Rate for Payer: CORVEL All Commercial |
$43.94
|
| Rate for Payer: Coventry All Commercial |
$41.58
|
| Rate for Payer: Encore All Commercial |
$43.49
|
| Rate for Payer: Frontpath All Commercial |
$43.47
|
| Rate for Payer: Humana ChoiceCare |
$40.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.52
|
| Rate for Payer: PHCS All Commercial |
$35.44
|
| Rate for Payer: PHP All Commercial |
$35.83
|
| Rate for Payer: Sagamore Health Network All Products |
$36.48
|
| Rate for Payer: Signature Care EPO |
$39.22
|
| Rate for Payer: Signature Care PPO |
$41.58
|
| Rate for Payer: United Healthcare Commercial |
$37.23
|
|
|
SODIUM CHLORIDE 0.9% IRRIGATION (BOLUS)
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
NDC 00338004804
|
| Hospital Charge Code |
408011403
|
|
Hospital Revenue Code
|
250
|
| 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 Hoosier Healthwise |
$37.28
|
| 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: 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: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| 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 0.9% IRRIGATION (BOLUS)
|
Facility
OP
|
$63.00
|
|
|
Service Code
|
NDC 004097972
|
| Hospital Charge Code |
408011403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.79 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$53.17
|
| Rate for Payer: Aetna Medicare |
$20.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$20.79
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$36.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.38
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.87
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Centivo All Commercial |
$32.13
|
| Rate for Payer: Cigna All Commercial |
$54.37
|
| Rate for Payer: CORVEL All Commercial |
$58.59
|
| Rate for Payer: Coventry All Commercial |
$55.44
|
| Rate for Payer: Encore All Commercial |
$57.99
|
| Rate for Payer: Frontpath All Commercial |
$57.96
|
| Rate for Payer: Humana ChoiceCare |
$54.41
|
| Rate for Payer: Humana Medicare |
$32.13
|
| Rate for Payer: Lucent All Commercial |
$32.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.70
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$47.25
|
| Rate for Payer: PHP All Commercial |
$47.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.57
|
| Rate for Payer: Sagamore Health Network All Products |
$48.64
|
| Rate for Payer: Signature Care EPO |
$52.29
|
| Rate for Payer: Signature Care PPO |
$55.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$53.55
|
| Rate for Payer: United Healthcare Commercial |
$49.64
|
| Rate for Payer: United Healthcare Medicare |
$20.79
|
|
|
SODIUM CHLORIDE 0.9% IRRIGATION (BOLUS)
|
Facility
IP
|
$63.00
|
|
|
Service Code
|
NDC 004097972
|
| Hospital Charge Code |
408011403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.25 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$54.43
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Cigna All Commercial |
$54.37
|
| Rate for Payer: CORVEL All Commercial |
$58.59
|
| Rate for Payer: Coventry All Commercial |
$55.44
|
| Rate for Payer: Encore All Commercial |
$57.99
|
| Rate for Payer: Frontpath All Commercial |
$57.96
|
| Rate for Payer: Humana ChoiceCare |
$54.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.70
|
| Rate for Payer: PHCS All Commercial |
$47.25
|
| Rate for Payer: PHP All Commercial |
$47.78
|
| Rate for Payer: Sagamore Health Network All Products |
$48.64
|
| Rate for Payer: Signature Care EPO |
$52.29
|
| Rate for Payer: Signature Care PPO |
$55.44
|
| Rate for Payer: United Healthcare Commercial |
$49.64
|
|
|
SODIUM CHLORIDE 0.9% IRRIGATION (BOLUS)
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
NDC 00338004805
|
| Hospital Charge Code |
408011403
|
|
Hospital Revenue Code
|
250
|
| 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 Hoosier Healthwise |
$37.28
|
| 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: 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: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| 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 0.9% IRRIGATION (BOLUS)
|
Facility
IP
|
$42.00
|
|
|
Service Code
|
NDC 00338004805
|
| Hospital Charge Code |
408011403
|
|
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 0.9% IRRIGATION (BOLUS)
|
Facility
IP
|
$42.00
|
|
|
Service Code
|
NDC 00338004804
|
| Hospital Charge Code |
408011403
|
|
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 0.9 % IR SOLN
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
NDC 00338004805
|
| Hospital Charge Code |
11403
|
|
Hospital Revenue Code
|
250
|
| 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 Hoosier Healthwise |
$37.28
|
| 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: 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: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| 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 0.9 % IR SOLN
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
NDC 00338004804
|
| Hospital Charge Code |
11403
|
|
Hospital Revenue Code
|
250
|
| 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 Hoosier Healthwise |
$37.28
|
| 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: 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: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| 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 0.9 % IR SOLN
|
Facility
IP
|
$63.00
|
|
|
Service Code
|
NDC 00990797208
|
| Hospital Charge Code |
11403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.25 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$54.43
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Cigna All Commercial |
$54.37
|
| Rate for Payer: CORVEL All Commercial |
$58.59
|
| Rate for Payer: Coventry All Commercial |
$55.44
|
| Rate for Payer: Encore All Commercial |
$57.99
|
| Rate for Payer: Frontpath All Commercial |
$57.96
|
| Rate for Payer: Humana ChoiceCare |
$54.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.70
|
| Rate for Payer: PHCS All Commercial |
$47.25
|
| Rate for Payer: PHP All Commercial |
$47.78
|
| Rate for Payer: Sagamore Health Network All Products |
$48.64
|
| Rate for Payer: Signature Care EPO |
$52.29
|
| Rate for Payer: Signature Care PPO |
$55.44
|
| Rate for Payer: United Healthcare Commercial |
$49.64
|
|
|
SODIUM CHLORIDE 0.9 % IR SOLN
|
Facility
OP
|
$63.00
|
|
|
Service Code
|
NDC 00990797208
|
| Hospital Charge Code |
11403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.79 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$53.17
|
| Rate for Payer: Aetna Medicare |
$20.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$20.79
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$36.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.38
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.87
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Centivo All Commercial |
$32.13
|
| Rate for Payer: Cigna All Commercial |
$54.37
|
| Rate for Payer: CORVEL All Commercial |
$58.59
|
| Rate for Payer: Coventry All Commercial |
$55.44
|
| Rate for Payer: Encore All Commercial |
$57.99
|
| Rate for Payer: Frontpath All Commercial |
$57.96
|
| Rate for Payer: Humana ChoiceCare |
$54.41
|
| Rate for Payer: Humana Medicare |
$32.13
|
| Rate for Payer: Lucent All Commercial |
$32.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.70
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$47.25
|
| Rate for Payer: PHP All Commercial |
$47.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.57
|
| Rate for Payer: Sagamore Health Network All Products |
$48.64
|
| Rate for Payer: Signature Care EPO |
$52.29
|
| Rate for Payer: Signature Care PPO |
$55.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$53.55
|
| Rate for Payer: United Healthcare Commercial |
$49.64
|
| Rate for Payer: United Healthcare Medicare |
$20.79
|
|
|
SODIUM CHLORIDE 0.9 % IR SOLN
|
Facility
IP
|
$42.00
|
|
|
Service Code
|
NDC 00338004805
|
| Hospital Charge Code |
11403
|
|
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 0.9 % IR SOLN
|
Facility
OP
|
$47.25
|
|
|
Service Code
|
NDC 00338004802
|
| Hospital Charge Code |
11403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.59 |
| Max. Negotiated Rate |
$43.94 |
| Rate for Payer: Aetna Commercial |
$39.88
|
| Rate for Payer: Aetna Medicare |
$15.59
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$27.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.15
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Centivo All Commercial |
$24.10
|
| Rate for Payer: Cigna All Commercial |
$40.78
|
| Rate for Payer: CORVEL All Commercial |
$43.94
|
| Rate for Payer: Coventry All Commercial |
$41.58
|
| Rate for Payer: Encore All Commercial |
$43.49
|
| Rate for Payer: Frontpath All Commercial |
$43.47
|
| Rate for Payer: Humana ChoiceCare |
$40.81
|
| Rate for Payer: Humana Medicare |
$24.10
|
| Rate for Payer: Lucent All Commercial |
$24.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.52
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$35.44
|
| Rate for Payer: PHP All Commercial |
$35.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.43
|
| Rate for Payer: Sagamore Health Network All Products |
$36.48
|
| Rate for Payer: Signature Care EPO |
$39.22
|
| Rate for Payer: Signature Care PPO |
$41.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.16
|
| Rate for Payer: United Healthcare Commercial |
$37.23
|
| Rate for Payer: United Healthcare Medicare |
$15.59
|
|
|
SODIUM CHLORIDE 0.9 % IR SOLN
|
Facility
IP
|
$294.00
|
|
|
Service Code
|
NDC 00338004727
|
| Hospital Charge Code |
11403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$220.50 |
| Max. Negotiated Rate |
$273.42 |
| Rate for Payer: Aetna Commercial |
$254.02
|
| Rate for Payer: Cash Price |
$182.28
|
| Rate for Payer: Cigna All Commercial |
$253.72
|
| Rate for Payer: CORVEL All Commercial |
$273.42
|
| Rate for Payer: Coventry All Commercial |
$258.72
|
| Rate for Payer: Encore All Commercial |
$270.63
|
| Rate for Payer: Frontpath All Commercial |
$270.48
|
| Rate for Payer: Humana ChoiceCare |
$253.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$264.60
|
| Rate for Payer: PHCS All Commercial |
$220.50
|
| Rate for Payer: PHP All Commercial |
$222.97
|
| Rate for Payer: Sagamore Health Network All Products |
$226.97
|
| Rate for Payer: Signature Care EPO |
$244.02
|
| Rate for Payer: Signature Care PPO |
$258.72
|
| Rate for Payer: United Healthcare Commercial |
$231.67
|
|
|
SODIUM CHLORIDE 0.9 % IR SOLN
|
Facility
OP
|
$294.00
|
|
|
Service Code
|
NDC 00338004727
|
| Hospital Charge Code |
11403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$273.42 |
| Rate for Payer: Aetna Commercial |
$248.14
|
| Rate for Payer: Aetna Medicare |
$97.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$97.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$168.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$183.78
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$111.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$106.72
|
| Rate for Payer: Cash Price |
$182.28
|
| Rate for Payer: Cash Price |
$182.28
|
| Rate for Payer: Centivo All Commercial |
$149.94
|
| Rate for Payer: Cigna All Commercial |
$253.72
|
| Rate for Payer: CORVEL All Commercial |
$273.42
|
| Rate for Payer: Coventry All Commercial |
$258.72
|
| Rate for Payer: Encore All Commercial |
$270.63
|
| Rate for Payer: Frontpath All Commercial |
$270.48
|
| Rate for Payer: Humana ChoiceCare |
$253.93
|
| Rate for Payer: Humana Medicare |
$149.94
|
| Rate for Payer: Lucent All Commercial |
$149.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$264.60
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$220.50
|
| Rate for Payer: PHP All Commercial |
$222.97
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$114.66
|
| Rate for Payer: Sagamore Health Network All Products |
$226.97
|
| Rate for Payer: Signature Care EPO |
$244.02
|
| Rate for Payer: Signature Care PPO |
$258.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$249.90
|
| Rate for Payer: United Healthcare Commercial |
$231.67
|
| Rate for Payer: United Healthcare Medicare |
$97.02
|
|
|
SODIUM CHLORIDE 0.9 % IR SOLN
|
Facility
IP
|
$47.25
|
|
|
Service Code
|
NDC 00338004802
|
| Hospital Charge Code |
11403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.44 |
| Max. Negotiated Rate |
$43.94 |
| Rate for Payer: Aetna Commercial |
$40.82
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cigna All Commercial |
$40.78
|
| Rate for Payer: CORVEL All Commercial |
$43.94
|
| Rate for Payer: Coventry All Commercial |
$41.58
|
| Rate for Payer: Encore All Commercial |
$43.49
|
| Rate for Payer: Frontpath All Commercial |
$43.47
|
| Rate for Payer: Humana ChoiceCare |
$40.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.52
|
| Rate for Payer: PHCS All Commercial |
$35.44
|
| Rate for Payer: PHP All Commercial |
$35.83
|
| Rate for Payer: Sagamore Health Network All Products |
$36.48
|
| Rate for Payer: Signature Care EPO |
$39.22
|
| Rate for Payer: Signature Care PPO |
$41.58
|
| Rate for Payer: United Healthcare Commercial |
$37.23
|
|
|
SODIUM CHLORIDE 0.9 % IR SOLN
|
Facility
IP
|
$42.00
|
|
|
Service Code
|
NDC 00338004804
|
| Hospital Charge Code |
11403
|
|
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
|
|
