|
DEXMEDETOMIDINE IN 0.9 % NACL 80 MCG/20 ML (4 MCG/ML) IV SOLN
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
171613
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.04 |
| Max. Negotiated Rate |
$78.12 |
| Rate for Payer: Aetna Commercial |
$70.90
|
| Rate for Payer: Aetna Medicare |
$26.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$26.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$48.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$52.51
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$29.57
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Centivo All Commercial |
$45.70
|
| Rate for Payer: Cigna All Commercial |
$72.49
|
| Rate for Payer: CORVEL All Commercial |
$78.12
|
| Rate for Payer: Coventry All Commercial |
$73.92
|
| Rate for Payer: Encore All Commercial |
$77.32
|
| Rate for Payer: Frontpath All Commercial |
$77.28
|
| Rate for Payer: Humana ChoiceCare |
$72.55
|
| Rate for Payer: Humana Medicare |
$26.88
|
| Rate for Payer: Lucent All Commercial |
$45.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.60
|
| Rate for Payer: PHCS All Commercial |
$63.00
|
| Rate for Payer: PHP All Commercial |
$63.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.76
|
| Rate for Payer: Sagamore Health Network All Products |
$64.85
|
| Rate for Payer: Signature Care EPO |
$69.72
|
| Rate for Payer: Signature Care PPO |
$73.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$71.40
|
| Rate for Payer: United Healthcare Commercial |
$66.19
|
| Rate for Payer: United Healthcare Medicare |
$26.88
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML ORAL SYRP
|
Facility
|
OP
|
$13.37
|
|
|
Service Code
|
NDC 00121127610
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.14 |
| Max. Negotiated Rate |
$12.43 |
| Rate for Payer: Aetna Commercial |
$11.28
|
| Rate for Payer: Aetna Medicare |
$4.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.71
|
| Rate for Payer: Cash Price |
$8.02
|
| Rate for Payer: Centivo All Commercial |
$7.27
|
| Rate for Payer: Cigna All Commercial |
$11.54
|
| Rate for Payer: CORVEL All Commercial |
$12.43
|
| Rate for Payer: Coventry All Commercial |
$11.77
|
| Rate for Payer: Encore All Commercial |
$12.31
|
| Rate for Payer: Frontpath All Commercial |
$12.30
|
| Rate for Payer: Humana ChoiceCare |
$11.55
|
| Rate for Payer: Humana Medicare |
$4.28
|
| Rate for Payer: Lucent All Commercial |
$7.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.03
|
| Rate for Payer: PHCS All Commercial |
$10.03
|
| Rate for Payer: PHP All Commercial |
$10.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.21
|
| Rate for Payer: Sagamore Health Network All Products |
$10.32
|
| Rate for Payer: Signature Care EPO |
$11.10
|
| Rate for Payer: Signature Care PPO |
$11.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.36
|
| Rate for Payer: United Healthcare Commercial |
$10.54
|
| Rate for Payer: United Healthcare Medicare |
$4.28
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML ORAL SYRP
|
Facility
|
IP
|
$13.37
|
|
|
Service Code
|
NDC 00121127610
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.03 |
| Max. Negotiated Rate |
$12.43 |
| Rate for Payer: Aetna Commercial |
$11.55
|
| Rate for Payer: Cash Price |
$8.02
|
| Rate for Payer: Cigna All Commercial |
$11.54
|
| Rate for Payer: CORVEL All Commercial |
$12.43
|
| Rate for Payer: Coventry All Commercial |
$11.77
|
| Rate for Payer: Encore All Commercial |
$12.31
|
| Rate for Payer: Frontpath All Commercial |
$12.30
|
| Rate for Payer: Humana ChoiceCare |
$11.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.03
|
| Rate for Payer: PHCS All Commercial |
$10.03
|
| Rate for Payer: PHP All Commercial |
$10.14
|
| Rate for Payer: Sagamore Health Network All Products |
$10.32
|
| Rate for Payer: Signature Care EPO |
$11.10
|
| Rate for Payer: Signature Care PPO |
$11.77
|
| Rate for Payer: United Healthcare Commercial |
$10.54
|
|
|
DEXTROSE 10 % IN WATER (D10W) 10 % IV SOLP
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.53 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$53.17
|
| Rate for Payer: Aetna Commercial |
$32.49
|
| Rate for Payer: Aetna Medicare |
$20.16
|
| Rate for Payer: Aetna Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$36.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$22.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.18
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Centivo All Commercial |
$20.94
|
| Rate for Payer: Centivo All Commercial |
$34.27
|
| Rate for Payer: Cigna All Commercial |
$54.37
|
| Rate for Payer: Cigna All Commercial |
$33.23
|
| Rate for Payer: CORVEL All Commercial |
$35.80
|
| Rate for Payer: CORVEL All Commercial |
$58.59
|
| Rate for Payer: Coventry All Commercial |
$33.88
|
| Rate for Payer: Coventry All Commercial |
$55.44
|
| Rate for Payer: Encore All Commercial |
$57.99
|
| Rate for Payer: Encore All Commercial |
$35.44
|
| Rate for Payer: Frontpath All Commercial |
$35.42
|
| Rate for Payer: Frontpath All Commercial |
$57.96
|
| Rate for Payer: Humana ChoiceCare |
$54.41
|
| Rate for Payer: Humana ChoiceCare |
$33.25
|
| Rate for Payer: Humana Medicare |
$20.16
|
| Rate for Payer: Humana Medicare |
$12.32
|
| Rate for Payer: Lucent All Commercial |
$20.94
|
| Rate for Payer: Lucent All Commercial |
$34.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.65
|
| Rate for Payer: PHCS All Commercial |
$28.88
|
| Rate for Payer: PHCS All Commercial |
$47.25
|
| Rate for Payer: PHP All Commercial |
$29.20
|
| Rate for Payer: PHP All Commercial |
$47.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.02
|
| Rate for Payer: Sagamore Health Network All Products |
$29.72
|
| Rate for Payer: Sagamore Health Network All Products |
$48.64
|
| Rate for Payer: Signature Care EPO |
$52.29
|
| Rate for Payer: Signature Care EPO |
$31.95
|
| Rate for Payer: Signature Care PPO |
$33.88
|
| Rate for Payer: Signature Care PPO |
$55.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$53.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$32.73
|
| Rate for Payer: United Healthcare Commercial |
$30.34
|
| Rate for Payer: United Healthcare Commercial |
$49.64
|
| Rate for Payer: United Healthcare Medicare |
$12.32
|
| Rate for Payer: United Healthcare Medicare |
$20.16
|
|
|
DEXTROSE 10 % IN WATER (D10W) 10 % IV SOLP
|
Facility
|
IP
|
$38.50
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
2357
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$28.88 |
| Max. Negotiated Rate |
$35.80 |
| Rate for Payer: Aetna Commercial |
$33.26
|
| Rate for Payer: Aetna Commercial |
$54.43
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna All Commercial |
$33.23
|
| Rate for Payer: Cigna All Commercial |
$54.37
|
| Rate for Payer: CORVEL All Commercial |
$35.80
|
| Rate for Payer: CORVEL All Commercial |
$58.59
|
| Rate for Payer: Coventry All Commercial |
$55.44
|
| Rate for Payer: Coventry All Commercial |
$33.88
|
| Rate for Payer: Encore All Commercial |
$57.99
|
| Rate for Payer: Encore All Commercial |
$35.44
|
| Rate for Payer: Frontpath All Commercial |
$35.42
|
| Rate for Payer: Frontpath All Commercial |
$57.96
|
| Rate for Payer: Humana ChoiceCare |
$33.25
|
| Rate for Payer: Humana ChoiceCare |
$54.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.70
|
| Rate for Payer: PHCS All Commercial |
$47.25
|
| Rate for Payer: PHCS All Commercial |
$28.88
|
| Rate for Payer: PHP All Commercial |
$29.20
|
| Rate for Payer: PHP All Commercial |
$47.78
|
| Rate for Payer: Sagamore Health Network All Products |
$48.64
|
| Rate for Payer: Sagamore Health Network All Products |
$29.72
|
| Rate for Payer: Signature Care EPO |
$52.29
|
| Rate for Payer: Signature Care EPO |
$31.95
|
| Rate for Payer: Signature Care PPO |
$33.88
|
| Rate for Payer: Signature Care PPO |
$55.44
|
| Rate for Payer: United Healthcare Commercial |
$30.34
|
| Rate for Payer: United Healthcare Commercial |
$49.64
|
|
|
DEXTROSE 10 % IN WATER (D10W) IV SOLP BOLUS
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
800169
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$47.25 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$54.43
|
| Rate for Payer: Cash Price |
$37.80
|
| 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
|
|
|
DEXTROSE 10 % IN WATER (D10W) IV SOLP BOLUS
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
800169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.53 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$53.17
|
| Rate for Payer: Aetna Medicare |
$20.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$36.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.18
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Centivo All Commercial |
$34.27
|
| 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 |
$20.16
|
| Rate for Payer: Lucent All Commercial |
$34.27
|
| 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: 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 |
$20.16
|
|
|
DEXTROSE 10 % IN WATER (D10W) IV SOLP (WEIGHT BASED)
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
800168
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$47.25 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$54.43
|
| Rate for Payer: Cash Price |
$37.80
|
| 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
|
|
|
DEXTROSE 10 % IN WATER (D10W) IV SOLP (WEIGHT BASED)
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
800168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.53 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$53.17
|
| Rate for Payer: Aetna Medicare |
$20.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$36.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.18
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Centivo All Commercial |
$34.27
|
| 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 |
$20.16
|
| Rate for Payer: Lucent All Commercial |
$34.27
|
| 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: 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 |
$20.16
|
|
|
DEXTROSE 15 GRAM/32 ML ORAL GLPK
|
Facility
|
OP
|
$13.66
|
|
|
Service Code
|
NDC 56151162501
|
| Hospital Charge Code |
183330
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$12.71 |
| Rate for Payer: Aetna Commercial |
$11.53
|
| Rate for Payer: Aetna Medicare |
$4.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$7.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.54
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.81
|
| Rate for Payer: Cash Price |
$8.20
|
| Rate for Payer: Centivo All Commercial |
$7.43
|
| Rate for Payer: Cigna All Commercial |
$11.79
|
| Rate for Payer: CORVEL All Commercial |
$12.71
|
| Rate for Payer: Coventry All Commercial |
$12.02
|
| Rate for Payer: Encore All Commercial |
$12.58
|
| Rate for Payer: Frontpath All Commercial |
$12.57
|
| Rate for Payer: Humana ChoiceCare |
$11.80
|
| Rate for Payer: Humana Medicare |
$4.37
|
| Rate for Payer: Lucent All Commercial |
$7.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.30
|
| Rate for Payer: PHCS All Commercial |
$10.25
|
| Rate for Payer: PHP All Commercial |
$10.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.33
|
| Rate for Payer: Sagamore Health Network All Products |
$10.55
|
| Rate for Payer: Signature Care EPO |
$11.34
|
| Rate for Payer: Signature Care PPO |
$12.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.61
|
| Rate for Payer: United Healthcare Commercial |
$10.77
|
| Rate for Payer: United Healthcare Medicare |
$4.37
|
|
|
DEXTROSE 15 GRAM/32 ML ORAL GLPK
|
Facility
|
IP
|
$13.66
|
|
|
Service Code
|
NDC 56151162501
|
| Hospital Charge Code |
183330
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$12.71 |
| Rate for Payer: Aetna Commercial |
$11.81
|
| Rate for Payer: Cash Price |
$8.20
|
| Rate for Payer: Cigna All Commercial |
$11.79
|
| Rate for Payer: CORVEL All Commercial |
$12.71
|
| Rate for Payer: Coventry All Commercial |
$12.02
|
| Rate for Payer: Encore All Commercial |
$12.58
|
| Rate for Payer: Frontpath All Commercial |
$12.57
|
| Rate for Payer: Humana ChoiceCare |
$11.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.30
|
| Rate for Payer: PHCS All Commercial |
$10.25
|
| Rate for Payer: PHP All Commercial |
$10.36
|
| Rate for Payer: Sagamore Health Network All Products |
$10.55
|
| Rate for Payer: Signature Care EPO |
$11.34
|
| Rate for Payer: Signature Care PPO |
$12.02
|
| Rate for Payer: United Healthcare Commercial |
$10.77
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
OP
|
$28.88
|
|
|
Service Code
|
NDC 00574006930
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$26.85 |
| Rate for Payer: Aetna Commercial |
$24.37
|
| Rate for Payer: Aetna Medicare |
$9.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.16
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Centivo All Commercial |
$15.71
|
| Rate for Payer: Cigna All Commercial |
$24.92
|
| Rate for Payer: CORVEL All Commercial |
$26.85
|
| Rate for Payer: Coventry All Commercial |
$25.41
|
| Rate for Payer: Encore All Commercial |
$26.58
|
| Rate for Payer: Frontpath All Commercial |
$26.57
|
| Rate for Payer: Humana ChoiceCare |
$24.94
|
| Rate for Payer: Humana Medicare |
$9.24
|
| Rate for Payer: Lucent All Commercial |
$15.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.99
|
| Rate for Payer: PHCS All Commercial |
$21.66
|
| Rate for Payer: PHP All Commercial |
$21.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.26
|
| Rate for Payer: Sagamore Health Network All Products |
$22.29
|
| Rate for Payer: Signature Care EPO |
$23.97
|
| Rate for Payer: Signature Care PPO |
$25.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.54
|
| Rate for Payer: United Healthcare Commercial |
$22.75
|
| Rate for Payer: United Healthcare Medicare |
$9.24
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
IP
|
$28.88
|
|
|
Service Code
|
NDC 00574006930
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.66 |
| Max. Negotiated Rate |
$26.85 |
| Rate for Payer: Aetna Commercial |
$24.95
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Cigna All Commercial |
$24.92
|
| Rate for Payer: CORVEL All Commercial |
$26.85
|
| Rate for Payer: Coventry All Commercial |
$25.41
|
| Rate for Payer: Encore All Commercial |
$26.58
|
| Rate for Payer: Frontpath All Commercial |
$26.57
|
| Rate for Payer: Humana ChoiceCare |
$24.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.99
|
| Rate for Payer: PHCS All Commercial |
$21.66
|
| Rate for Payer: PHP All Commercial |
$21.90
|
| Rate for Payer: Sagamore Health Network All Products |
$22.29
|
| Rate for Payer: Signature Care EPO |
$23.97
|
| Rate for Payer: Signature Care PPO |
$25.41
|
| Rate for Payer: United Healthcare Commercial |
$22.75
|
|
|
DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
9812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.78
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Centivo All Commercial |
$22.85
|
| 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 |
$13.44
|
| Rate for Payer: Lucent All Commercial |
$22.85
|
| 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 |
$13.44
|
|
|
DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
9812
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$25.20
|
| 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
|
|
|
DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
9812
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$45.57 |
| Rate for Payer: Aetna Commercial |
$42.34
|
| Rate for Payer: Aetna Commercial |
$39.31
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna All Commercial |
$39.27
|
| Rate for Payer: Cigna All Commercial |
$42.29
|
| Rate for Payer: CORVEL All Commercial |
$45.57
|
| Rate for Payer: CORVEL All Commercial |
$42.31
|
| Rate for Payer: Coventry All Commercial |
$43.12
|
| Rate for Payer: Coventry All Commercial |
$40.04
|
| Rate for Payer: Encore All Commercial |
$41.88
|
| Rate for Payer: Encore All Commercial |
$45.10
|
| Rate for Payer: Frontpath All Commercial |
$45.08
|
| Rate for Payer: Frontpath All Commercial |
$41.86
|
| Rate for Payer: Humana ChoiceCare |
$39.30
|
| Rate for Payer: Humana ChoiceCare |
$42.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$40.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.10
|
| Rate for Payer: PHCS All Commercial |
$34.12
|
| Rate for Payer: PHCS All Commercial |
$36.75
|
| Rate for Payer: PHP All Commercial |
$37.16
|
| Rate for Payer: PHP All Commercial |
$34.51
|
| Rate for Payer: Sagamore Health Network All Products |
$35.13
|
| Rate for Payer: Sagamore Health Network All Products |
$37.83
|
| Rate for Payer: Signature Care EPO |
$40.67
|
| Rate for Payer: Signature Care EPO |
$37.77
|
| Rate for Payer: Signature Care PPO |
$40.04
|
| Rate for Payer: Signature Care PPO |
$43.12
|
| Rate for Payer: United Healthcare Commercial |
$35.85
|
| Rate for Payer: United Healthcare Commercial |
$38.61
|
|
|
DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP
|
Facility
|
OP
|
$45.50
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
9812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.11 |
| Max. Negotiated Rate |
$42.31 |
| Rate for Payer: Aetna Commercial |
$38.40
|
| Rate for Payer: Aetna Commercial |
$41.36
|
| Rate for Payer: Aetna Medicare |
$14.56
|
| Rate for Payer: Aetna Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$28.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$26.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$28.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$16.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.25
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Centivo All Commercial |
$24.75
|
| Rate for Payer: Centivo All Commercial |
$26.66
|
| Rate for Payer: Cigna All Commercial |
$39.27
|
| Rate for Payer: Cigna All Commercial |
$42.29
|
| Rate for Payer: CORVEL All Commercial |
$45.57
|
| Rate for Payer: CORVEL All Commercial |
$42.31
|
| Rate for Payer: Coventry All Commercial |
$43.12
|
| Rate for Payer: Coventry All Commercial |
$40.04
|
| Rate for Payer: Encore All Commercial |
$41.88
|
| Rate for Payer: Encore All Commercial |
$45.10
|
| Rate for Payer: Frontpath All Commercial |
$41.86
|
| Rate for Payer: Frontpath All Commercial |
$45.08
|
| Rate for Payer: Humana ChoiceCare |
$42.32
|
| Rate for Payer: Humana ChoiceCare |
$39.30
|
| Rate for Payer: Humana Medicare |
$15.68
|
| Rate for Payer: Humana Medicare |
$14.56
|
| Rate for Payer: Lucent All Commercial |
$24.75
|
| Rate for Payer: Lucent All Commercial |
$26.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$40.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.10
|
| Rate for Payer: PHCS All Commercial |
$36.75
|
| Rate for Payer: PHCS All Commercial |
$34.12
|
| Rate for Payer: PHP All Commercial |
$34.51
|
| Rate for Payer: PHP All Commercial |
$37.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$17.75
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.11
|
| Rate for Payer: Sagamore Health Network All Products |
$35.13
|
| Rate for Payer: Sagamore Health Network All Products |
$37.83
|
| Rate for Payer: Signature Care EPO |
$37.77
|
| Rate for Payer: Signature Care EPO |
$40.67
|
| Rate for Payer: Signature Care PPO |
$40.04
|
| Rate for Payer: Signature Care PPO |
$43.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$38.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.65
|
| Rate for Payer: United Healthcare Commercial |
$38.61
|
| Rate for Payer: United Healthcare Commercial |
$35.85
|
| Rate for Payer: United Healthcare Medicare |
$15.68
|
| Rate for Payer: United Healthcare Medicare |
$14.56
|
|
|
DEXTROSE 50 % IN WATER (D50W) IV SYRG
|
Facility
|
OP
|
$116.20
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
114043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.02 |
| Max. Negotiated Rate |
$108.07 |
| Rate for Payer: Aetna Commercial |
$98.07
|
| Rate for Payer: Aetna Medicare |
$37.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$36.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$66.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$72.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$42.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$40.90
|
| Rate for Payer: Cash Price |
$69.72
|
| Rate for Payer: Centivo All Commercial |
$63.21
|
| Rate for Payer: Cigna All Commercial |
$100.28
|
| Rate for Payer: CORVEL All Commercial |
$108.07
|
| Rate for Payer: Coventry All Commercial |
$102.26
|
| Rate for Payer: Encore All Commercial |
$106.96
|
| Rate for Payer: Frontpath All Commercial |
$106.90
|
| Rate for Payer: Humana ChoiceCare |
$100.36
|
| Rate for Payer: Humana Medicare |
$37.18
|
| Rate for Payer: Lucent All Commercial |
$63.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$104.58
|
| Rate for Payer: PHCS All Commercial |
$87.15
|
| Rate for Payer: PHP All Commercial |
$88.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$45.32
|
| Rate for Payer: Sagamore Health Network All Products |
$89.71
|
| Rate for Payer: Signature Care EPO |
$96.45
|
| Rate for Payer: Signature Care PPO |
$102.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$98.77
|
| Rate for Payer: United Healthcare Commercial |
$91.57
|
| Rate for Payer: United Healthcare Medicare |
$37.18
|
|
|
DEXTROSE 50 % IN WATER (D50W) IV SYRG
|
Facility
|
IP
|
$116.20
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
114043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.15 |
| Max. Negotiated Rate |
$108.07 |
| Rate for Payer: Aetna Commercial |
$100.40
|
| Rate for Payer: Cash Price |
$69.72
|
| Rate for Payer: Cigna All Commercial |
$100.28
|
| Rate for Payer: CORVEL All Commercial |
$108.07
|
| Rate for Payer: Coventry All Commercial |
$102.26
|
| Rate for Payer: Encore All Commercial |
$106.96
|
| Rate for Payer: Frontpath All Commercial |
$106.90
|
| Rate for Payer: Humana ChoiceCare |
$100.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$104.58
|
| Rate for Payer: PHCS All Commercial |
$87.15
|
| Rate for Payer: PHP All Commercial |
$88.13
|
| Rate for Payer: Sagamore Health Network All Products |
$89.71
|
| Rate for Payer: Signature Care EPO |
$96.45
|
| Rate for Payer: Signature Care PPO |
$102.26
|
| Rate for Payer: United Healthcare Commercial |
$91.57
|
|
|
DEXTROSE 5 % IN WATER (D5W) IV SOLP
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.78
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Centivo All Commercial |
$22.85
|
| 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 |
$13.44
|
| Rate for Payer: Lucent All Commercial |
$22.85
|
| 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 |
$13.44
|
|
|
DEXTROSE 5 % IN WATER (D5W) IV SOLP
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$26.04 |
| Rate for Payer: Aetna Commercial |
$23.63
|
| Rate for Payer: Aetna Commercial |
$26.59
|
| Rate for Payer: Aetna Commercial |
$16.54
|
| Rate for Payer: Aetna Medicare |
$10.08
|
| Rate for Payer: Aetna Medicare |
$6.27
|
| Rate for Payer: Aetna Medicare |
$8.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.26
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$18.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.69
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.90
|
| Rate for Payer: Cash Price |
$11.76
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Centivo All Commercial |
$15.23
|
| Rate for Payer: Centivo All Commercial |
$17.14
|
| Rate for Payer: Centivo All Commercial |
$10.66
|
| Rate for Payer: Cigna All Commercial |
$27.18
|
| Rate for Payer: Cigna All Commercial |
$24.16
|
| Rate for Payer: Cigna All Commercial |
$16.91
|
| Rate for Payer: CORVEL All Commercial |
$29.30
|
| Rate for Payer: CORVEL All Commercial |
$26.04
|
| Rate for Payer: CORVEL All Commercial |
$18.23
|
| Rate for Payer: Coventry All Commercial |
$27.72
|
| Rate for Payer: Coventry All Commercial |
$17.25
|
| Rate for Payer: Coventry All Commercial |
$24.64
|
| Rate for Payer: Encore All Commercial |
$25.77
|
| Rate for Payer: Encore All Commercial |
$18.04
|
| Rate for Payer: Encore All Commercial |
$29.00
|
| Rate for Payer: Frontpath All Commercial |
$18.03
|
| Rate for Payer: Frontpath All Commercial |
$28.98
|
| Rate for Payer: Frontpath All Commercial |
$25.76
|
| Rate for Payer: Humana ChoiceCare |
$27.21
|
| Rate for Payer: Humana ChoiceCare |
$24.18
|
| Rate for Payer: Humana ChoiceCare |
$16.93
|
| Rate for Payer: Humana Medicare |
$6.27
|
| Rate for Payer: Humana Medicare |
$8.96
|
| Rate for Payer: Humana Medicare |
$10.08
|
| Rate for Payer: Lucent All Commercial |
$17.14
|
| Rate for Payer: Lucent All Commercial |
$10.66
|
| Rate for Payer: Lucent All Commercial |
$15.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.20
|
| Rate for Payer: PHCS All Commercial |
$23.62
|
| Rate for Payer: PHCS All Commercial |
$21.00
|
| Rate for Payer: PHCS All Commercial |
$14.70
|
| Rate for Payer: PHP All Commercial |
$21.24
|
| Rate for Payer: PHP All Commercial |
$23.89
|
| Rate for Payer: PHP All Commercial |
$14.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.92
|
| Rate for Payer: Sagamore Health Network All Products |
$24.32
|
| Rate for Payer: Sagamore Health Network All Products |
$21.62
|
| Rate for Payer: Sagamore Health Network All Products |
$15.13
|
| Rate for Payer: Signature Care EPO |
$16.27
|
| Rate for Payer: Signature Care EPO |
$26.14
|
| Rate for Payer: Signature Care EPO |
$23.24
|
| Rate for Payer: Signature Care PPO |
$17.25
|
| Rate for Payer: Signature Care PPO |
$24.64
|
| Rate for Payer: Signature Care PPO |
$27.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.77
|
| Rate for Payer: United Healthcare Commercial |
$22.06
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
| Rate for Payer: United Healthcare Commercial |
$15.44
|
| Rate for Payer: United Healthcare Medicare |
$6.27
|
| Rate for Payer: United Healthcare Medicare |
$8.96
|
| Rate for Payer: United Healthcare Medicare |
$10.08
|
|
|
DEXTROSE 5 % IN WATER (D5W) IV SOLP
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$25.20
|
| 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
|
|
|
DEXTROSE 5 % IN WATER (D5W) IV SOLP
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$26.04 |
| Rate for Payer: Aetna Commercial |
$24.19
|
| Rate for Payer: Aetna Commercial |
$16.93
|
| Rate for Payer: Aetna Commercial |
$27.22
|
| Rate for Payer: Cash Price |
$11.76
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna All Commercial |
$24.16
|
| Rate for Payer: Cigna All Commercial |
$16.91
|
| Rate for Payer: Cigna All Commercial |
$27.18
|
| Rate for Payer: CORVEL All Commercial |
$29.30
|
| Rate for Payer: CORVEL All Commercial |
$18.23
|
| Rate for Payer: CORVEL All Commercial |
$26.04
|
| Rate for Payer: Coventry All Commercial |
$17.25
|
| Rate for Payer: Coventry All Commercial |
$27.72
|
| Rate for Payer: Coventry All Commercial |
$24.64
|
| Rate for Payer: Encore All Commercial |
$25.77
|
| Rate for Payer: Encore All Commercial |
$18.04
|
| Rate for Payer: Encore All Commercial |
$29.00
|
| Rate for Payer: Frontpath All Commercial |
$28.98
|
| Rate for Payer: Frontpath All Commercial |
$18.03
|
| Rate for Payer: Frontpath All Commercial |
$25.76
|
| Rate for Payer: Humana ChoiceCare |
$24.18
|
| Rate for Payer: Humana ChoiceCare |
$16.93
|
| Rate for Payer: Humana ChoiceCare |
$27.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.35
|
| Rate for Payer: PHCS All Commercial |
$21.00
|
| Rate for Payer: PHCS All Commercial |
$14.70
|
| Rate for Payer: PHCS All Commercial |
$23.62
|
| Rate for Payer: PHP All Commercial |
$21.24
|
| Rate for Payer: PHP All Commercial |
$14.86
|
| Rate for Payer: PHP All Commercial |
$23.89
|
| Rate for Payer: Sagamore Health Network All Products |
$24.32
|
| Rate for Payer: Sagamore Health Network All Products |
$21.62
|
| Rate for Payer: Sagamore Health Network All Products |
$15.13
|
| Rate for Payer: Signature Care EPO |
$23.24
|
| Rate for Payer: Signature Care EPO |
$16.27
|
| Rate for Payer: Signature Care EPO |
$26.14
|
| Rate for Payer: Signature Care PPO |
$17.25
|
| Rate for Payer: Signature Care PPO |
$27.72
|
| Rate for Payer: Signature Care PPO |
$24.64
|
| Rate for Payer: United Healthcare Commercial |
$22.06
|
| Rate for Payer: United Healthcare Commercial |
$24.82
|
| Rate for Payer: United Healthcare Commercial |
$15.44
|
|
|
DEXTROSE 5% IN WATER (D5W) LINE CARE - 100 ML BAG - CAMERON
|
Facility
|
OP
|
$19.60
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
14010002364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$18.23 |
| Rate for Payer: Aetna Commercial |
$16.54
|
| Rate for Payer: Aetna Medicare |
$6.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.26
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.90
|
| Rate for Payer: Cash Price |
$11.76
|
| Rate for Payer: Centivo All Commercial |
$10.66
|
| Rate for Payer: Cigna All Commercial |
$16.91
|
| Rate for Payer: CORVEL All Commercial |
$18.23
|
| Rate for Payer: Coventry All Commercial |
$17.25
|
| Rate for Payer: Encore All Commercial |
$18.04
|
| Rate for Payer: Frontpath All Commercial |
$18.03
|
| Rate for Payer: Humana ChoiceCare |
$16.93
|
| Rate for Payer: Humana Medicare |
$6.27
|
| Rate for Payer: Lucent All Commercial |
$10.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.64
|
| Rate for Payer: PHCS All Commercial |
$14.70
|
| Rate for Payer: PHP All Commercial |
$14.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.64
|
| Rate for Payer: Sagamore Health Network All Products |
$15.13
|
| Rate for Payer: Signature Care EPO |
$16.27
|
| Rate for Payer: Signature Care PPO |
$17.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.66
|
| Rate for Payer: United Healthcare Commercial |
$15.44
|
| Rate for Payer: United Healthcare Medicare |
$6.27
|
|
|
DEXTROSE 5% IN WATER (D5W) LINE CARE - 100 ML BAG - CAMERON
|
Facility
|
IP
|
$19.60
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
14010002364
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$18.23 |
| Rate for Payer: Aetna Commercial |
$16.93
|
| Rate for Payer: Cash Price |
$11.76
|
| Rate for Payer: Cigna All Commercial |
$16.91
|
| Rate for Payer: CORVEL All Commercial |
$18.23
|
| Rate for Payer: Coventry All Commercial |
$17.25
|
| Rate for Payer: Encore All Commercial |
$18.04
|
| Rate for Payer: Frontpath All Commercial |
$18.03
|
| Rate for Payer: Humana ChoiceCare |
$16.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.64
|
| Rate for Payer: PHCS All Commercial |
$14.70
|
| Rate for Payer: PHP All Commercial |
$14.86
|
| Rate for Payer: Sagamore Health Network All Products |
$15.13
|
| Rate for Payer: Signature Care EPO |
$16.27
|
| Rate for Payer: Signature Care PPO |
$17.25
|
| Rate for Payer: United Healthcare Commercial |
$15.44
|
|
