|
SODIUM CHLORIDE 4 MEQ/ML IV SOLN
|
Facility
IP
|
$49.77
|
|
|
Service Code
|
NDC 63323009330
|
| Hospital Charge Code |
7322
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$37.33 |
| Max. Negotiated Rate |
$46.29 |
| Rate for Payer: Aetna Commercial |
$43.00
|
| Rate for Payer: Cash Price |
$30.86
|
| Rate for Payer: Cigna All Commercial |
$42.95
|
| Rate for Payer: CORVEL All Commercial |
$46.29
|
| Rate for Payer: Coventry All Commercial |
$43.80
|
| Rate for Payer: Encore All Commercial |
$45.81
|
| Rate for Payer: Frontpath All Commercial |
$45.79
|
| Rate for Payer: Humana ChoiceCare |
$42.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.79
|
| Rate for Payer: PHCS All Commercial |
$37.33
|
| Rate for Payer: PHP All Commercial |
$37.75
|
| Rate for Payer: Sagamore Health Network All Products |
$38.42
|
| Rate for Payer: Signature Care EPO |
$41.31
|
| Rate for Payer: Signature Care PPO |
$43.80
|
| Rate for Payer: United Healthcare Commercial |
$39.22
|
|
|
SODIUM CITRATE-CITRIC ACID 500-334 MG/5 ML ORAL SOLN
|
Facility
IP
|
$31.92
|
|
|
Service Code
|
NDC 00121119000
|
| Hospital Charge Code |
15706
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.94 |
| Max. Negotiated Rate |
$29.69 |
| Rate for Payer: Aetna Commercial |
$27.58
|
| Rate for Payer: Cash Price |
$19.79
|
| Rate for Payer: Cigna All Commercial |
$27.55
|
| Rate for Payer: CORVEL All Commercial |
$29.69
|
| Rate for Payer: Coventry All Commercial |
$28.09
|
| Rate for Payer: Encore All Commercial |
$29.38
|
| Rate for Payer: Frontpath All Commercial |
$29.37
|
| Rate for Payer: Humana ChoiceCare |
$27.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.73
|
| Rate for Payer: PHCS All Commercial |
$23.94
|
| Rate for Payer: PHP All Commercial |
$24.21
|
| Rate for Payer: Sagamore Health Network All Products |
$24.64
|
| Rate for Payer: Signature Care EPO |
$26.49
|
| Rate for Payer: Signature Care PPO |
$28.09
|
| Rate for Payer: United Healthcare Commercial |
$25.15
|
|
|
SODIUM CITRATE-CITRIC ACID 500-334 MG/5 ML ORAL SOLN
|
Facility
OP
|
$31.92
|
|
|
Service Code
|
NDC 00121119000
|
| Hospital Charge Code |
15706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$29.69 |
| Rate for Payer: Aetna Commercial |
$26.94
|
| Rate for Payer: Aetna Medicare |
$10.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$18.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.59
|
| Rate for Payer: Cash Price |
$19.79
|
| Rate for Payer: Centivo All Commercial |
$16.28
|
| Rate for Payer: Cigna All Commercial |
$27.55
|
| Rate for Payer: CORVEL All Commercial |
$29.69
|
| Rate for Payer: Coventry All Commercial |
$28.09
|
| Rate for Payer: Encore All Commercial |
$29.38
|
| Rate for Payer: Frontpath All Commercial |
$29.37
|
| Rate for Payer: Humana ChoiceCare |
$27.57
|
| Rate for Payer: Humana Medicare |
$16.28
|
| Rate for Payer: Lucent All Commercial |
$16.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.73
|
| Rate for Payer: PHCS All Commercial |
$23.94
|
| Rate for Payer: PHP All Commercial |
$24.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.45
|
| Rate for Payer: Sagamore Health Network All Products |
$24.64
|
| Rate for Payer: Signature Care EPO |
$26.49
|
| Rate for Payer: Signature Care PPO |
$28.09
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27.13
|
| Rate for Payer: United Healthcare Commercial |
$25.15
|
| Rate for Payer: United Healthcare Medicare |
$10.53
|
|
|
SODIUM FLUORIDE F-18 10-200 MCI/ML 370-7,400MBQ/ML IV SOLN
|
Facility
OP
|
$15,800.40
|
|
|
Service Code
|
NDC 65857030030
|
| Hospital Charge Code |
192110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$14,694.37 |
| Rate for Payer: Aetna Commercial |
$13,335.54
|
| Rate for Payer: Aetna Medicare |
$5,214.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5,214.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9,074.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9,876.83
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5,996.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5,735.55
|
| Rate for Payer: Cash Price |
$9,796.25
|
| Rate for Payer: Cash Price |
$9,796.25
|
| Rate for Payer: Centivo All Commercial |
$8,058.20
|
| Rate for Payer: Cigna All Commercial |
$13,635.75
|
| Rate for Payer: CORVEL All Commercial |
$14,694.37
|
| Rate for Payer: Coventry All Commercial |
$13,904.35
|
| Rate for Payer: Encore All Commercial |
$14,544.27
|
| Rate for Payer: Frontpath All Commercial |
$14,536.37
|
| Rate for Payer: Humana ChoiceCare |
$13,646.81
|
| Rate for Payer: Humana Medicare |
$8,058.20
|
| Rate for Payer: Lucent All Commercial |
$8,058.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,220.36
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$11,850.30
|
| Rate for Payer: PHP All Commercial |
$11,983.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,162.16
|
| Rate for Payer: Sagamore Health Network All Products |
$12,197.91
|
| Rate for Payer: Signature Care EPO |
$13,114.33
|
| Rate for Payer: Signature Care PPO |
$13,904.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,430.34
|
| Rate for Payer: United Healthcare Commercial |
$12,450.72
|
| Rate for Payer: United Healthcare Medicare |
$5,214.13
|
|
|
SODIUM FLUORIDE F-18 10-200 MCI/ML 370-7,400MBQ/ML IV SOLN
|
Facility
IP
|
$15,800.40
|
|
|
Service Code
|
NDC 65857030030
|
| Hospital Charge Code |
192110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11,850.30 |
| Max. Negotiated Rate |
$14,694.37 |
| Rate for Payer: Aetna Commercial |
$13,651.55
|
| Rate for Payer: Cash Price |
$9,796.25
|
| Rate for Payer: Cigna All Commercial |
$13,635.75
|
| Rate for Payer: CORVEL All Commercial |
$14,694.37
|
| Rate for Payer: Coventry All Commercial |
$13,904.35
|
| Rate for Payer: Encore All Commercial |
$14,544.27
|
| Rate for Payer: Frontpath All Commercial |
$14,536.37
|
| Rate for Payer: Humana ChoiceCare |
$13,646.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,220.36
|
| Rate for Payer: PHCS All Commercial |
$11,850.30
|
| Rate for Payer: PHP All Commercial |
$11,983.02
|
| Rate for Payer: Sagamore Health Network All Products |
$12,197.91
|
| Rate for Payer: Signature Care EPO |
$13,114.33
|
| Rate for Payer: Signature Care PPO |
$13,904.35
|
| Rate for Payer: United Healthcare Commercial |
$12,450.72
|
|
|
SODIUM HYALURONATE (VISCOSUP) 10 MG/ML(MW 2.4 -3.6 MILLION) IATC SYRG
|
Facility
IP
|
$829.93
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
179484
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$622.45 |
| Max. Negotiated Rate |
$771.83 |
| Rate for Payer: Aetna Commercial |
$717.06
|
| Rate for Payer: Cash Price |
$514.56
|
| Rate for Payer: Cigna All Commercial |
$716.23
|
| Rate for Payer: CORVEL All Commercial |
$771.83
|
| Rate for Payer: Coventry All Commercial |
$730.34
|
| Rate for Payer: Encore All Commercial |
$763.95
|
| Rate for Payer: Frontpath All Commercial |
$763.54
|
| Rate for Payer: Humana ChoiceCare |
$716.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$746.94
|
| Rate for Payer: PHCS All Commercial |
$622.45
|
| Rate for Payer: PHP All Commercial |
$629.42
|
| Rate for Payer: Sagamore Health Network All Products |
$640.71
|
| Rate for Payer: Signature Care EPO |
$688.84
|
| Rate for Payer: Signature Care PPO |
$730.34
|
| Rate for Payer: United Healthcare Commercial |
$653.98
|
|
|
SODIUM HYALURONATE (VISCOSUP) 10 MG/ML(MW 2.4 -3.6 MILLION) IATC SYRG
|
Facility
OP
|
$829.93
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
179484
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$273.88 |
| Max. Negotiated Rate |
$771.83 |
| Rate for Payer: Aetna Commercial |
$700.46
|
| Rate for Payer: Aetna Medicare |
$273.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$273.88
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$476.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$518.79
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$367.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$314.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$301.26
|
| Rate for Payer: Cash Price |
$514.56
|
| Rate for Payer: Cash Price |
$514.56
|
| Rate for Payer: Centivo All Commercial |
$423.26
|
| Rate for Payer: Cigna All Commercial |
$716.23
|
| Rate for Payer: CORVEL All Commercial |
$771.83
|
| Rate for Payer: Coventry All Commercial |
$730.34
|
| Rate for Payer: Encore All Commercial |
$763.95
|
| Rate for Payer: Frontpath All Commercial |
$763.54
|
| Rate for Payer: Humana ChoiceCare |
$716.81
|
| Rate for Payer: Humana Medicare |
$423.26
|
| Rate for Payer: Lucent All Commercial |
$423.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$746.94
|
| Rate for Payer: Managed Health Services Medicaid |
$367.63
|
| Rate for Payer: MDWise Medicaid |
$367.63
|
| Rate for Payer: PHCS All Commercial |
$622.45
|
| Rate for Payer: PHP All Commercial |
$629.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$323.67
|
| Rate for Payer: Sagamore Health Network All Products |
$640.71
|
| Rate for Payer: Signature Care EPO |
$688.84
|
| Rate for Payer: Signature Care PPO |
$730.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$705.44
|
| Rate for Payer: United Healthcare Commercial |
$653.98
|
| Rate for Payer: United Healthcare Medicare |
$273.88
|
|
|
SODIUM HYPOCHLORITE 0.125 % MISC SOLN
|
Facility
OP
|
$105.95
|
|
|
Service Code
|
NDC 00436067216
|
| Hospital Charge Code |
76720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.96 |
| Max. Negotiated Rate |
$98.54 |
| Rate for Payer: Aetna Commercial |
$89.42
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$60.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$66.23
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$38.46
|
| Rate for Payer: Cash Price |
$65.69
|
| Rate for Payer: Centivo All Commercial |
$54.04
|
| Rate for Payer: Cigna All Commercial |
$91.44
|
| Rate for Payer: CORVEL All Commercial |
$98.54
|
| Rate for Payer: Coventry All Commercial |
$93.24
|
| Rate for Payer: Encore All Commercial |
$97.53
|
| Rate for Payer: Frontpath All Commercial |
$97.48
|
| Rate for Payer: Humana ChoiceCare |
$91.51
|
| Rate for Payer: Humana Medicare |
$54.04
|
| Rate for Payer: Lucent All Commercial |
$54.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$95.36
|
| Rate for Payer: PHCS All Commercial |
$79.46
|
| Rate for Payer: PHP All Commercial |
$80.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.32
|
| Rate for Payer: Sagamore Health Network All Products |
$81.79
|
| Rate for Payer: Signature Care EPO |
$87.94
|
| Rate for Payer: Signature Care PPO |
$93.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$90.06
|
| Rate for Payer: United Healthcare Commercial |
$83.49
|
| Rate for Payer: United Healthcare Medicare |
$34.96
|
|
|
SODIUM HYPOCHLORITE 0.125 % MISC SOLN
|
Facility
IP
|
$105.95
|
|
|
Service Code
|
NDC 00436067216
|
| Hospital Charge Code |
76720
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.46 |
| Max. Negotiated Rate |
$98.54 |
| Rate for Payer: Aetna Commercial |
$91.54
|
| Rate for Payer: Cash Price |
$65.69
|
| Rate for Payer: Cigna All Commercial |
$91.44
|
| Rate for Payer: CORVEL All Commercial |
$98.54
|
| Rate for Payer: Coventry All Commercial |
$93.24
|
| Rate for Payer: Encore All Commercial |
$97.53
|
| Rate for Payer: Frontpath All Commercial |
$97.48
|
| Rate for Payer: Humana ChoiceCare |
$91.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$95.36
|
| Rate for Payer: PHCS All Commercial |
$79.46
|
| Rate for Payer: PHP All Commercial |
$80.35
|
| Rate for Payer: Sagamore Health Network All Products |
$81.79
|
| Rate for Payer: Signature Care EPO |
$87.94
|
| Rate for Payer: Signature Care PPO |
$93.24
|
| Rate for Payer: United Healthcare Commercial |
$83.49
|
|
|
SODIUM IODIDE-123 7.4 MBQ (200 MICROCI) ORAL CAP
|
Facility
IP
|
$531.96
|
|
|
Service Code
|
HCPCS A9516
|
| Hospital Charge Code |
4080157044
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$398.97 |
| Max. Negotiated Rate |
$494.72 |
| Rate for Payer: Aetna Commercial |
$459.61
|
| Rate for Payer: Cash Price |
$329.82
|
| Rate for Payer: Cigna All Commercial |
$459.08
|
| Rate for Payer: CORVEL All Commercial |
$494.72
|
| Rate for Payer: Coventry All Commercial |
$468.12
|
| Rate for Payer: Encore All Commercial |
$489.67
|
| Rate for Payer: Frontpath All Commercial |
$489.40
|
| Rate for Payer: Humana ChoiceCare |
$459.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$478.76
|
| Rate for Payer: PHCS All Commercial |
$398.97
|
| Rate for Payer: PHP All Commercial |
$403.44
|
| Rate for Payer: Sagamore Health Network All Products |
$410.67
|
| Rate for Payer: Signature Care EPO |
$441.53
|
| Rate for Payer: Signature Care PPO |
$468.12
|
| Rate for Payer: United Healthcare Commercial |
$419.18
|
|
|
SODIUM IODIDE-123 7.4 MBQ (200 MICROCI) ORAL CAP
|
Facility
OP
|
$531.96
|
|
|
Service Code
|
HCPCS A9516
|
| Hospital Charge Code |
4080157044
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$175.55 |
| Max. Negotiated Rate |
$494.72 |
| Rate for Payer: Aetna Commercial |
$448.97
|
| Rate for Payer: Aetna Medicare |
$175.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$175.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$305.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$332.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$201.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$193.10
|
| Rate for Payer: Cash Price |
$329.82
|
| Rate for Payer: Centivo All Commercial |
$271.30
|
| Rate for Payer: Cigna All Commercial |
$459.08
|
| Rate for Payer: CORVEL All Commercial |
$494.72
|
| Rate for Payer: Coventry All Commercial |
$468.12
|
| Rate for Payer: Encore All Commercial |
$489.67
|
| Rate for Payer: Frontpath All Commercial |
$489.40
|
| Rate for Payer: Humana ChoiceCare |
$459.45
|
| Rate for Payer: Humana Medicare |
$271.30
|
| Rate for Payer: Lucent All Commercial |
$271.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$478.76
|
| Rate for Payer: PHCS All Commercial |
$398.97
|
| Rate for Payer: PHP All Commercial |
$403.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$207.46
|
| Rate for Payer: Sagamore Health Network All Products |
$410.67
|
| Rate for Payer: Signature Care EPO |
$441.53
|
| Rate for Payer: Signature Care PPO |
$468.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$452.17
|
| Rate for Payer: United Healthcare Commercial |
$419.18
|
| Rate for Payer: United Healthcare Medicare |
$175.55
|
|
|
SODIUM NITRITE-SOD THIOSULFATE 300 MG/10 ML- 12.5 GRAM/50 ML IV SOLN
|
Facility
OP
|
$950.10
|
|
|
Service Code
|
NDC 60267081200
|
| Hospital Charge Code |
109784
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$883.59 |
| Rate for Payer: Aetna Commercial |
$801.88
|
| Rate for Payer: Aetna Medicare |
$313.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$313.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$545.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$593.91
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$360.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$344.89
|
| Rate for Payer: Cash Price |
$589.06
|
| Rate for Payer: Cash Price |
$589.06
|
| Rate for Payer: Centivo All Commercial |
$484.55
|
| Rate for Payer: Cigna All Commercial |
$819.94
|
| Rate for Payer: CORVEL All Commercial |
$883.59
|
| Rate for Payer: Coventry All Commercial |
$836.09
|
| Rate for Payer: Encore All Commercial |
$874.57
|
| Rate for Payer: Frontpath All Commercial |
$874.09
|
| Rate for Payer: Humana ChoiceCare |
$820.60
|
| Rate for Payer: Humana Medicare |
$484.55
|
| Rate for Payer: Lucent All Commercial |
$484.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$855.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$712.58
|
| Rate for Payer: PHP All Commercial |
$720.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$370.54
|
| Rate for Payer: Sagamore Health Network All Products |
$733.48
|
| Rate for Payer: Signature Care EPO |
$788.58
|
| Rate for Payer: Signature Care PPO |
$836.09
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$807.58
|
| Rate for Payer: United Healthcare Commercial |
$748.68
|
| Rate for Payer: United Healthcare Medicare |
$313.53
|
|
|
SODIUM NITRITE-SOD THIOSULFATE 300 MG/10 ML- 12.5 GRAM/50 ML IV SOLN
|
Facility
IP
|
$950.10
|
|
|
Service Code
|
NDC 60267081200
|
| Hospital Charge Code |
109784
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$712.58 |
| Max. Negotiated Rate |
$883.59 |
| Rate for Payer: Aetna Commercial |
$820.89
|
| Rate for Payer: Cash Price |
$589.06
|
| Rate for Payer: Cigna All Commercial |
$819.94
|
| Rate for Payer: CORVEL All Commercial |
$883.59
|
| Rate for Payer: Coventry All Commercial |
$836.09
|
| Rate for Payer: Encore All Commercial |
$874.57
|
| Rate for Payer: Frontpath All Commercial |
$874.09
|
| Rate for Payer: Humana ChoiceCare |
$820.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$855.09
|
| Rate for Payer: PHCS All Commercial |
$712.58
|
| Rate for Payer: PHP All Commercial |
$720.56
|
| Rate for Payer: Sagamore Health Network All Products |
$733.48
|
| Rate for Payer: Signature Care EPO |
$788.58
|
| Rate for Payer: Signature Care PPO |
$836.09
|
| Rate for Payer: United Healthcare Commercial |
$748.68
|
|
|
SODIUM PERTECHNETATE TC 99M INJECTION
|
Facility
OP
|
$525.90
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
40840066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$173.55 |
| Max. Negotiated Rate |
$489.09 |
| Rate for Payer: Aetna Commercial |
$443.86
|
| Rate for Payer: Aetna Medicare |
$173.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$173.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$302.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$328.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$199.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$190.90
|
| Rate for Payer: Cash Price |
$326.06
|
| Rate for Payer: Centivo All Commercial |
$268.21
|
| Rate for Payer: Cigna All Commercial |
$453.85
|
| Rate for Payer: CORVEL All Commercial |
$489.09
|
| Rate for Payer: Coventry All Commercial |
$462.79
|
| Rate for Payer: Encore All Commercial |
$484.09
|
| Rate for Payer: Frontpath All Commercial |
$483.83
|
| Rate for Payer: Humana ChoiceCare |
$454.22
|
| Rate for Payer: Humana Medicare |
$268.21
|
| Rate for Payer: Lucent All Commercial |
$268.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$473.31
|
| Rate for Payer: PHCS All Commercial |
$394.43
|
| Rate for Payer: PHP All Commercial |
$398.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$205.10
|
| Rate for Payer: Sagamore Health Network All Products |
$406.00
|
| Rate for Payer: Signature Care EPO |
$436.50
|
| Rate for Payer: Signature Care PPO |
$462.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$447.02
|
| Rate for Payer: United Healthcare Commercial |
$414.41
|
| Rate for Payer: United Healthcare Medicare |
$173.55
|
|
|
SODIUM PERTECHNETATE TC 99M INJECTION
|
Facility
IP
|
$525.90
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
40840066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$394.43 |
| Max. Negotiated Rate |
$489.09 |
| Rate for Payer: Aetna Commercial |
$454.38
|
| Rate for Payer: Cash Price |
$326.06
|
| Rate for Payer: Cigna All Commercial |
$453.85
|
| Rate for Payer: CORVEL All Commercial |
$489.09
|
| Rate for Payer: Coventry All Commercial |
$462.79
|
| Rate for Payer: Encore All Commercial |
$484.09
|
| Rate for Payer: Frontpath All Commercial |
$483.83
|
| Rate for Payer: Humana ChoiceCare |
$454.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$473.31
|
| Rate for Payer: PHCS All Commercial |
$394.43
|
| Rate for Payer: PHP All Commercial |
$398.84
|
| Rate for Payer: Sagamore Health Network All Products |
$406.00
|
| Rate for Payer: Signature Care EPO |
$436.50
|
| Rate for Payer: Signature Care PPO |
$462.79
|
| Rate for Payer: United Healthcare Commercial |
$414.41
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN
|
Facility
OP
|
$137.83
|
|
|
Service Code
|
NDC 63323017005
|
| Hospital Charge Code |
7351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$128.18 |
| Rate for Payer: Aetna Commercial |
$116.33
|
| Rate for Payer: Aetna Medicare |
$45.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$45.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$79.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$86.16
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$52.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$50.03
|
| Rate for Payer: Cash Price |
$85.45
|
| Rate for Payer: Cash Price |
$85.45
|
| Rate for Payer: Centivo All Commercial |
$70.29
|
| Rate for Payer: Cigna All Commercial |
$118.95
|
| Rate for Payer: CORVEL All Commercial |
$128.18
|
| Rate for Payer: Coventry All Commercial |
$121.29
|
| Rate for Payer: Encore All Commercial |
$126.87
|
| Rate for Payer: Frontpath All Commercial |
$126.80
|
| Rate for Payer: Humana ChoiceCare |
$119.04
|
| Rate for Payer: Humana Medicare |
$70.29
|
| Rate for Payer: Lucent All Commercial |
$70.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$124.05
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$103.37
|
| Rate for Payer: PHP All Commercial |
$104.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$53.75
|
| Rate for Payer: Sagamore Health Network All Products |
$106.40
|
| Rate for Payer: Signature Care EPO |
$114.40
|
| Rate for Payer: Signature Care PPO |
$121.29
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$117.16
|
| Rate for Payer: United Healthcare Commercial |
$108.61
|
| Rate for Payer: United Healthcare Medicare |
$45.48
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN
|
Facility
IP
|
$137.83
|
|
|
Service Code
|
NDC 63323017005
|
| Hospital Charge Code |
7351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.37 |
| Max. Negotiated Rate |
$128.18 |
| Rate for Payer: Aetna Commercial |
$119.09
|
| Rate for Payer: Cash Price |
$85.45
|
| Rate for Payer: Cigna All Commercial |
$118.95
|
| Rate for Payer: CORVEL All Commercial |
$128.18
|
| Rate for Payer: Coventry All Commercial |
$121.29
|
| Rate for Payer: Encore All Commercial |
$126.87
|
| Rate for Payer: Frontpath All Commercial |
$126.80
|
| Rate for Payer: Humana ChoiceCare |
$119.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$124.05
|
| Rate for Payer: PHCS All Commercial |
$103.37
|
| Rate for Payer: PHP All Commercial |
$104.53
|
| Rate for Payer: Sagamore Health Network All Products |
$106.40
|
| Rate for Payer: Signature Care EPO |
$114.40
|
| Rate for Payer: Signature Care PPO |
$121.29
|
| Rate for Payer: United Healthcare Commercial |
$108.61
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 G ORAL PWPK
|
Facility
IP
|
$143.46
|
|
|
Service Code
|
NDC 00310110539
|
| Hospital Charge Code |
185534
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.59 |
| Max. Negotiated Rate |
$133.42 |
| Rate for Payer: Aetna Commercial |
$123.95
|
| Rate for Payer: Cash Price |
$88.94
|
| Rate for Payer: Cigna All Commercial |
$123.80
|
| Rate for Payer: CORVEL All Commercial |
$133.42
|
| Rate for Payer: Coventry All Commercial |
$126.24
|
| Rate for Payer: Encore All Commercial |
$132.05
|
| Rate for Payer: Frontpath All Commercial |
$131.98
|
| Rate for Payer: Humana ChoiceCare |
$123.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.11
|
| Rate for Payer: PHCS All Commercial |
$107.59
|
| Rate for Payer: PHP All Commercial |
$108.80
|
| Rate for Payer: Sagamore Health Network All Products |
$110.75
|
| Rate for Payer: Signature Care EPO |
$119.07
|
| Rate for Payer: Signature Care PPO |
$126.24
|
| Rate for Payer: United Healthcare Commercial |
$113.04
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 G ORAL PWPK
|
Facility
OP
|
$143.46
|
|
|
Service Code
|
NDC 00310110539
|
| Hospital Charge Code |
185534
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.34 |
| Max. Negotiated Rate |
$133.42 |
| Rate for Payer: Aetna Commercial |
$121.08
|
| Rate for Payer: Aetna Medicare |
$47.34
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$47.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$82.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$89.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$54.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$52.08
|
| Rate for Payer: Cash Price |
$88.94
|
| Rate for Payer: Centivo All Commercial |
$73.16
|
| Rate for Payer: Cigna All Commercial |
$123.80
|
| Rate for Payer: CORVEL All Commercial |
$133.42
|
| Rate for Payer: Coventry All Commercial |
$126.24
|
| Rate for Payer: Encore All Commercial |
$132.05
|
| Rate for Payer: Frontpath All Commercial |
$131.98
|
| Rate for Payer: Humana ChoiceCare |
$123.90
|
| Rate for Payer: Humana Medicare |
$73.16
|
| Rate for Payer: Lucent All Commercial |
$73.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.11
|
| Rate for Payer: PHCS All Commercial |
$107.59
|
| Rate for Payer: PHP All Commercial |
$108.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$55.95
|
| Rate for Payer: Sagamore Health Network All Products |
$110.75
|
| Rate for Payer: Signature Care EPO |
$119.07
|
| Rate for Payer: Signature Care PPO |
$126.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$121.94
|
| Rate for Payer: United Healthcare Commercial |
$113.04
|
| Rate for Payer: United Healthcare Medicare |
$47.34
|
|
|
SOD PHOS DI, MONO-K PHOS MONO 250 MG ORAL TAB
|
Facility
IP
|
$1.77
|
|
|
Service Code
|
NDC 64980010401
|
| Hospital Charge Code |
11067
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cigna All Commercial |
$1.53
|
| Rate for Payer: CORVEL All Commercial |
$1.65
|
| Rate for Payer: Coventry All Commercial |
$1.56
|
| Rate for Payer: Encore All Commercial |
$1.63
|
| Rate for Payer: Frontpath All Commercial |
$1.63
|
| Rate for Payer: Humana ChoiceCare |
$1.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.59
|
| Rate for Payer: PHCS All Commercial |
$1.33
|
| Rate for Payer: PHP All Commercial |
$1.34
|
| Rate for Payer: Sagamore Health Network All Products |
$1.37
|
| Rate for Payer: Signature Care EPO |
$1.47
|
| Rate for Payer: Signature Care PPO |
$1.56
|
| Rate for Payer: United Healthcare Commercial |
$1.40
|
|
|
SOD PHOS DI, MONO-K PHOS MONO 250 MG ORAL TAB
|
Facility
OP
|
$1.77
|
|
|
Service Code
|
NDC 64980010401
|
| Hospital Charge Code |
11067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna Commercial |
$1.49
|
| Rate for Payer: Aetna Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.11
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Centivo All Commercial |
$0.90
|
| Rate for Payer: Cigna All Commercial |
$1.53
|
| Rate for Payer: CORVEL All Commercial |
$1.65
|
| Rate for Payer: Coventry All Commercial |
$1.56
|
| Rate for Payer: Encore All Commercial |
$1.63
|
| Rate for Payer: Frontpath All Commercial |
$1.63
|
| Rate for Payer: Humana ChoiceCare |
$1.53
|
| Rate for Payer: Humana Medicare |
$0.90
|
| Rate for Payer: Lucent All Commercial |
$0.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.59
|
| Rate for Payer: PHCS All Commercial |
$1.33
|
| Rate for Payer: PHP All Commercial |
$1.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.69
|
| Rate for Payer: Sagamore Health Network All Products |
$1.37
|
| Rate for Payer: Signature Care EPO |
$1.47
|
| Rate for Payer: Signature Care PPO |
$1.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.51
|
| Rate for Payer: United Healthcare Commercial |
$1.40
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
|
|
SORBITOL 70 % MISC SOLN
|
Facility
OP
|
$21.21
|
|
|
Service Code
|
NDC 46287050030
|
| Hospital Charge Code |
7413
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$19.73 |
| Rate for Payer: Aetna Commercial |
$17.90
|
| Rate for Payer: Aetna Medicare |
$7.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$12.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.70
|
| Rate for Payer: Cash Price |
$13.15
|
| Rate for Payer: Centivo All Commercial |
$10.82
|
| Rate for Payer: Cigna All Commercial |
$18.30
|
| Rate for Payer: CORVEL All Commercial |
$19.73
|
| Rate for Payer: Coventry All Commercial |
$18.66
|
| Rate for Payer: Encore All Commercial |
$19.52
|
| Rate for Payer: Frontpath All Commercial |
$19.51
|
| Rate for Payer: Humana ChoiceCare |
$18.32
|
| Rate for Payer: Humana Medicare |
$10.82
|
| Rate for Payer: Lucent All Commercial |
$10.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.09
|
| Rate for Payer: PHCS All Commercial |
$15.91
|
| Rate for Payer: PHP All Commercial |
$16.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.27
|
| Rate for Payer: Sagamore Health Network All Products |
$16.37
|
| Rate for Payer: Signature Care EPO |
$17.60
|
| Rate for Payer: Signature Care PPO |
$18.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.03
|
| Rate for Payer: United Healthcare Commercial |
$16.71
|
| Rate for Payer: United Healthcare Medicare |
$7.00
|
|
|
SORBITOL 70 % MISC SOLN
|
Facility
IP
|
$21.21
|
|
|
Service Code
|
NDC 46287050030
|
| Hospital Charge Code |
7413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$19.73 |
| Rate for Payer: Aetna Commercial |
$18.33
|
| Rate for Payer: Cash Price |
$13.15
|
| Rate for Payer: Cigna All Commercial |
$18.30
|
| Rate for Payer: CORVEL All Commercial |
$19.73
|
| Rate for Payer: Coventry All Commercial |
$18.66
|
| Rate for Payer: Encore All Commercial |
$19.52
|
| Rate for Payer: Frontpath All Commercial |
$19.51
|
| Rate for Payer: Humana ChoiceCare |
$18.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.09
|
| Rate for Payer: PHCS All Commercial |
$15.91
|
| Rate for Payer: PHP All Commercial |
$16.09
|
| Rate for Payer: Sagamore Health Network All Products |
$16.37
|
| Rate for Payer: Signature Care EPO |
$17.60
|
| Rate for Payer: Signature Care PPO |
$18.66
|
| Rate for Payer: United Healthcare Commercial |
$16.71
|
|
|
SORBITOL-MANNITOL-XANTHAN GUM ORAL LIQD
|
Facility
IP
|
$52.50
|
|
|
Service Code
|
NDC 15137002127
|
| Hospital Charge Code |
192690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.38 |
| Max. Negotiated Rate |
$48.82 |
| Rate for Payer: Aetna Commercial |
$45.36
|
| Rate for Payer: Cash Price |
$32.55
|
| Rate for Payer: Cigna All Commercial |
$45.31
|
| Rate for Payer: CORVEL All Commercial |
$48.82
|
| Rate for Payer: Coventry All Commercial |
$46.20
|
| Rate for Payer: Encore All Commercial |
$48.33
|
| Rate for Payer: Frontpath All Commercial |
$48.30
|
| Rate for Payer: Humana ChoiceCare |
$45.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$47.25
|
| Rate for Payer: PHCS All Commercial |
$39.38
|
| Rate for Payer: PHP All Commercial |
$39.82
|
| Rate for Payer: Sagamore Health Network All Products |
$40.53
|
| Rate for Payer: Signature Care EPO |
$43.58
|
| Rate for Payer: Signature Care PPO |
$46.20
|
| Rate for Payer: United Healthcare Commercial |
$41.37
|
|
|
SORBITOL-MANNITOL-XANTHAN GUM ORAL LIQD
|
Facility
OP
|
$52.50
|
|
|
Service Code
|
NDC 15137002127
|
| Hospital Charge Code |
192690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.32 |
| Max. Negotiated Rate |
$48.82 |
| Rate for Payer: Aetna Commercial |
$44.31
|
| Rate for Payer: Aetna Medicare |
$17.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$30.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$32.82
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$19.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.06
|
| Rate for Payer: Cash Price |
$32.55
|
| Rate for Payer: Cash Price |
$32.55
|
| Rate for Payer: Centivo All Commercial |
$26.78
|
| Rate for Payer: Cigna All Commercial |
$45.31
|
| Rate for Payer: CORVEL All Commercial |
$48.82
|
| Rate for Payer: Coventry All Commercial |
$46.20
|
| Rate for Payer: Encore All Commercial |
$48.33
|
| Rate for Payer: Frontpath All Commercial |
$48.30
|
| Rate for Payer: Humana ChoiceCare |
$45.34
|
| Rate for Payer: Humana Medicare |
$26.78
|
| Rate for Payer: Lucent All Commercial |
$26.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$47.25
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$39.38
|
| Rate for Payer: PHP All Commercial |
$39.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$20.48
|
| Rate for Payer: Sagamore Health Network All Products |
$40.53
|
| Rate for Payer: Signature Care EPO |
$43.58
|
| Rate for Payer: Signature Care PPO |
$46.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$44.62
|
| Rate for Payer: United Healthcare Commercial |
$41.37
|
| Rate for Payer: United Healthcare Medicare |
$17.32
|
|
