|
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN
|
Facility
|
OP
|
$196.70
|
|
|
Service Code
|
NDC 00338955712
|
| Hospital Charge Code |
163887
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$182.93 |
| Rate for Payer: Aetna Commercial |
$166.01
|
| Rate for Payer: Aetna Medicare |
$64.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$64.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$112.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$122.96
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$74.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$71.40
|
| Rate for Payer: Cash Price |
$121.95
|
| Rate for Payer: Cash Price |
$121.95
|
| Rate for Payer: Centivo All Commercial |
$100.32
|
| Rate for Payer: Cigna All Commercial |
$169.75
|
| Rate for Payer: CORVEL All Commercial |
$182.93
|
| Rate for Payer: Coventry All Commercial |
$173.10
|
| Rate for Payer: Encore All Commercial |
$181.06
|
| Rate for Payer: Frontpath All Commercial |
$180.96
|
| Rate for Payer: Humana ChoiceCare |
$169.89
|
| Rate for Payer: Humana Medicare |
$100.32
|
| Rate for Payer: Lucent All Commercial |
$100.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$177.03
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$147.52
|
| Rate for Payer: PHP All Commercial |
$149.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$76.71
|
| Rate for Payer: Sagamore Health Network All Products |
$151.85
|
| Rate for Payer: Signature Care EPO |
$163.26
|
| Rate for Payer: Signature Care PPO |
$173.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$167.20
|
| Rate for Payer: United Healthcare Commercial |
$155.00
|
| Rate for Payer: United Healthcare Medicare |
$64.91
|
|
|
DEXMEDETOMIDINE IN 0.9 % NACL 80 MCG/20 ML (4 MCG/ML) IV SOLN
|
Facility
|
IP
|
$84.98
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
171613
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.74 |
| Max. Negotiated Rate |
$79.03 |
| Rate for Payer: Aetna Commercial |
$73.42
|
| Rate for Payer: Cash Price |
$52.69
|
| Rate for Payer: Cigna All Commercial |
$73.34
|
| Rate for Payer: CORVEL All Commercial |
$79.03
|
| Rate for Payer: Coventry All Commercial |
$74.78
|
| Rate for Payer: Encore All Commercial |
$78.22
|
| Rate for Payer: Frontpath All Commercial |
$78.18
|
| Rate for Payer: Humana ChoiceCare |
$73.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$76.48
|
| Rate for Payer: PHCS All Commercial |
$63.74
|
| Rate for Payer: PHP All Commercial |
$64.45
|
| Rate for Payer: Sagamore Health Network All Products |
$65.60
|
| Rate for Payer: Signature Care EPO |
$70.53
|
| Rate for Payer: Signature Care PPO |
$74.78
|
| Rate for Payer: United Healthcare Commercial |
$66.96
|
|
|
DEXMEDETOMIDINE IN 0.9 % NACL 80 MCG/20 ML (4 MCG/ML) IV SOLN
|
Facility
|
OP
|
$84.98
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
171613
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.04 |
| Max. Negotiated Rate |
$79.03 |
| Rate for Payer: Aetna Commercial |
$71.72
|
| Rate for Payer: Aetna Medicare |
$28.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$28.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$48.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$53.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$32.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$30.85
|
| Rate for Payer: Cash Price |
$52.69
|
| Rate for Payer: Centivo All Commercial |
$43.34
|
| Rate for Payer: Cigna All Commercial |
$73.34
|
| Rate for Payer: CORVEL All Commercial |
$79.03
|
| Rate for Payer: Coventry All Commercial |
$74.78
|
| Rate for Payer: Encore All Commercial |
$78.22
|
| Rate for Payer: Frontpath All Commercial |
$78.18
|
| Rate for Payer: Humana ChoiceCare |
$73.40
|
| Rate for Payer: Humana Medicare |
$43.34
|
| Rate for Payer: Lucent All Commercial |
$43.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$76.48
|
| Rate for Payer: PHCS All Commercial |
$63.74
|
| Rate for Payer: PHP All Commercial |
$64.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$33.14
|
| Rate for Payer: Sagamore Health Network All Products |
$65.60
|
| Rate for Payer: Signature Care EPO |
$70.53
|
| Rate for Payer: Signature Care PPO |
$74.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$72.23
|
| Rate for Payer: United Healthcare Commercial |
$66.96
|
| Rate for Payer: United Healthcare Medicare |
$28.04
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML ORAL SYRP
|
Facility
|
OP
|
$13.44
|
|
|
Service Code
|
NDC 00121127610
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$12.50 |
| Rate for Payer: Aetna Commercial |
$11.34
|
| Rate for Payer: Aetna Medicare |
$4.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.88
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: Centivo All Commercial |
$6.85
|
| Rate for Payer: Cigna All Commercial |
$11.60
|
| Rate for Payer: CORVEL All Commercial |
$12.50
|
| Rate for Payer: Coventry All Commercial |
$11.83
|
| Rate for Payer: Encore All Commercial |
$12.37
|
| Rate for Payer: Frontpath All Commercial |
$12.36
|
| Rate for Payer: Humana ChoiceCare |
$11.61
|
| Rate for Payer: Humana Medicare |
$6.85
|
| Rate for Payer: Lucent All Commercial |
$6.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.10
|
| Rate for Payer: PHCS All Commercial |
$10.08
|
| Rate for Payer: PHP All Commercial |
$10.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.24
|
| Rate for Payer: Sagamore Health Network All Products |
$10.38
|
| Rate for Payer: Signature Care EPO |
$11.16
|
| Rate for Payer: Signature Care PPO |
$11.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.42
|
| Rate for Payer: United Healthcare Commercial |
$10.59
|
| Rate for Payer: United Healthcare Medicare |
$4.44
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML ORAL SYRP
|
Facility
|
IP
|
$13.44
|
|
|
Service Code
|
NDC 00121127610
|
| Hospital Charge Code |
9774
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$12.50 |
| Rate for Payer: Aetna Commercial |
$11.61
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: Cigna All Commercial |
$11.60
|
| Rate for Payer: CORVEL All Commercial |
$12.50
|
| Rate for Payer: Coventry All Commercial |
$11.83
|
| Rate for Payer: Encore All Commercial |
$12.37
|
| Rate for Payer: Frontpath All Commercial |
$12.36
|
| Rate for Payer: Humana ChoiceCare |
$11.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.10
|
| Rate for Payer: PHCS All Commercial |
$10.08
|
| Rate for Payer: PHP All Commercial |
$10.19
|
| Rate for Payer: Sagamore Health Network All Products |
$10.38
|
| Rate for Payer: Signature Care EPO |
$11.16
|
| Rate for Payer: Signature Care PPO |
$11.83
|
| Rate for Payer: United Healthcare Commercial |
$10.59
|
|
|
DEXTROSE 10 % IN WATER (D10W) 10 % IV SOLP
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
2357
|
|
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 |
$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
|
|
|
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 |
$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 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: 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: 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
|
|
|
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 |
$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 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: 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: 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
|
|
|
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 |
$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
|
|
|
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 |
$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
|
|
|
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 |
$20.79 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Medicare |
$20.79
|
| Rate for Payer: Aetna Commercial |
$53.17
|
| 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 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: 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: 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
|
|
|
DEXTROSE 15 GRAM/32 ML ORAL GLPK
|
Facility
|
OP
|
$13.44
|
|
|
Service Code
|
NDC 56151162501
|
| Hospital Charge Code |
183330
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$12.50 |
| Rate for Payer: Aetna Commercial |
$11.34
|
| Rate for Payer: Aetna Medicare |
$4.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.88
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: Centivo All Commercial |
$6.85
|
| Rate for Payer: Cigna All Commercial |
$11.60
|
| Rate for Payer: CORVEL All Commercial |
$12.50
|
| Rate for Payer: Coventry All Commercial |
$11.83
|
| Rate for Payer: Encore All Commercial |
$12.37
|
| Rate for Payer: Frontpath All Commercial |
$12.36
|
| Rate for Payer: Humana ChoiceCare |
$11.61
|
| Rate for Payer: Humana Medicare |
$6.85
|
| Rate for Payer: Lucent All Commercial |
$6.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.10
|
| Rate for Payer: PHCS All Commercial |
$10.08
|
| Rate for Payer: PHP All Commercial |
$10.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.24
|
| Rate for Payer: Sagamore Health Network All Products |
$10.38
|
| Rate for Payer: Signature Care EPO |
$11.16
|
| Rate for Payer: Signature Care PPO |
$11.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.42
|
| Rate for Payer: United Healthcare Commercial |
$10.59
|
| Rate for Payer: United Healthcare Medicare |
$4.44
|
|
|
DEXTROSE 15 GRAM/32 ML ORAL GLPK
|
Facility
|
IP
|
$13.44
|
|
|
Service Code
|
NDC 56151162501
|
| Hospital Charge Code |
183330
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$12.50 |
| Rate for Payer: Aetna Commercial |
$11.61
|
| Rate for Payer: Cash Price |
$8.33
|
| Rate for Payer: Cigna All Commercial |
$11.60
|
| Rate for Payer: CORVEL All Commercial |
$12.50
|
| Rate for Payer: Coventry All Commercial |
$11.83
|
| Rate for Payer: Encore All Commercial |
$12.37
|
| Rate for Payer: Frontpath All Commercial |
$12.36
|
| Rate for Payer: Humana ChoiceCare |
$11.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.10
|
| Rate for Payer: PHCS All Commercial |
$10.08
|
| Rate for Payer: PHP All Commercial |
$10.19
|
| Rate for Payer: Sagamore Health Network All Products |
$10.38
|
| Rate for Payer: Signature Care EPO |
$11.16
|
| Rate for Payer: Signature Care PPO |
$11.83
|
| Rate for Payer: United Healthcare Commercial |
$10.59
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
IP
|
$28.61
|
|
|
Service Code
|
NDC 00574006930
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.46 |
| Max. Negotiated Rate |
$26.61 |
| Rate for Payer: Aetna Commercial |
$24.72
|
| Rate for Payer: Cash Price |
$17.74
|
| Rate for Payer: Cigna All Commercial |
$24.69
|
| Rate for Payer: CORVEL All Commercial |
$26.61
|
| Rate for Payer: Coventry All Commercial |
$25.18
|
| Rate for Payer: Encore All Commercial |
$26.34
|
| Rate for Payer: Frontpath All Commercial |
$26.32
|
| Rate for Payer: Humana ChoiceCare |
$24.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.75
|
| Rate for Payer: PHCS All Commercial |
$21.46
|
| Rate for Payer: PHP All Commercial |
$21.70
|
| Rate for Payer: Sagamore Health Network All Products |
$22.09
|
| Rate for Payer: Signature Care EPO |
$23.75
|
| Rate for Payer: Signature Care PPO |
$25.18
|
| Rate for Payer: United Healthcare Commercial |
$22.55
|
|
|
DEXTROSE 40 % ORAL GEL
|
Facility
|
OP
|
$28.61
|
|
|
Service Code
|
NDC 00574006930
|
| Hospital Charge Code |
27466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$26.61 |
| Rate for Payer: Aetna Commercial |
$24.15
|
| Rate for Payer: Aetna Medicare |
$9.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.89
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.39
|
| Rate for Payer: Cash Price |
$17.74
|
| Rate for Payer: Centivo All Commercial |
$14.59
|
| Rate for Payer: Cigna All Commercial |
$24.69
|
| Rate for Payer: CORVEL All Commercial |
$26.61
|
| Rate for Payer: Coventry All Commercial |
$25.18
|
| Rate for Payer: Encore All Commercial |
$26.34
|
| Rate for Payer: Frontpath All Commercial |
$26.32
|
| Rate for Payer: Humana ChoiceCare |
$24.71
|
| Rate for Payer: Humana Medicare |
$14.59
|
| Rate for Payer: Lucent All Commercial |
$14.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.75
|
| Rate for Payer: PHCS All Commercial |
$21.46
|
| Rate for Payer: PHP All Commercial |
$21.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.16
|
| Rate for Payer: Sagamore Health Network All Products |
$22.09
|
| Rate for Payer: Signature Care EPO |
$23.75
|
| Rate for Payer: Signature Care PPO |
$25.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.32
|
| Rate for Payer: United Healthcare Commercial |
$22.55
|
| Rate for Payer: United Healthcare Medicare |
$9.44
|
|
|
DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP
|
Facility
|
OP
|
$38.50
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
9812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.70 |
| Max. Negotiated Rate |
$35.80 |
| Rate for Payer: Aetna Commercial |
$32.49
|
| Rate for Payer: Aetna Medicare |
$12.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$22.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.98
|
| Rate for Payer: Cash Price |
$23.87
|
| Rate for Payer: Centivo All Commercial |
$19.64
|
| Rate for Payer: Cigna All Commercial |
$33.23
|
| Rate for Payer: CORVEL All Commercial |
$35.80
|
| Rate for Payer: Coventry All Commercial |
$33.88
|
| Rate for Payer: Encore All Commercial |
$35.44
|
| Rate for Payer: Frontpath All Commercial |
$35.42
|
| Rate for Payer: Humana ChoiceCare |
$33.25
|
| Rate for Payer: Humana Medicare |
$19.64
|
| Rate for Payer: Lucent All Commercial |
$19.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.65
|
| Rate for Payer: PHCS All Commercial |
$28.88
|
| Rate for Payer: PHP All Commercial |
$29.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.02
|
| Rate for Payer: Sagamore Health Network All Products |
$29.72
|
| Rate for Payer: Signature Care EPO |
$31.96
|
| Rate for Payer: Signature Care PPO |
$33.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$32.72
|
| Rate for Payer: United Healthcare Commercial |
$30.34
|
| Rate for Payer: United Healthcare Medicare |
$12.70
|
|
|
DEXTROSE 5%-0.2 % SOD CHLORIDE IV SOLP
|
Facility
|
IP
|
$38.50
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
9812
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$28.88 |
| Max. Negotiated Rate |
$35.80 |
| Rate for Payer: Aetna Commercial |
$33.26
|
| Rate for Payer: Cash Price |
$23.87
|
| Rate for Payer: Cigna All Commercial |
$33.23
|
| Rate for Payer: CORVEL All Commercial |
$35.80
|
| Rate for Payer: Coventry All Commercial |
$33.88
|
| Rate for Payer: Encore All Commercial |
$35.44
|
| Rate for Payer: Frontpath All Commercial |
$35.42
|
| Rate for Payer: Humana ChoiceCare |
$33.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.65
|
| Rate for Payer: PHCS All Commercial |
$28.88
|
| Rate for Payer: PHP All Commercial |
$29.20
|
| Rate for Payer: Sagamore Health Network All Products |
$29.72
|
| Rate for Payer: Signature Care EPO |
$31.96
|
| Rate for Payer: Signature Care PPO |
$33.88
|
| Rate for Payer: United Healthcare Commercial |
$30.34
|
|
|
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 |
$13.86 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.25
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Centivo All Commercial |
$21.42
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Humana Medicare |
$21.42
|
| Rate for Payer: Lucent All Commercial |
$21.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.86
|
|
|
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 |
$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
|
|
|
DEXTROSE 50 % IN WATER (D50W) IV SYRG
|
Facility
|
OP
|
$106.75
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
114043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.23 |
| Max. Negotiated Rate |
$99.28 |
| Rate for Payer: Aetna Commercial |
$90.10
|
| Rate for Payer: Aetna Medicare |
$35.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$61.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$66.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.51
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$38.75
|
| Rate for Payer: Cash Price |
$66.19
|
| Rate for Payer: Centivo All Commercial |
$54.44
|
| Rate for Payer: Cigna All Commercial |
$92.13
|
| Rate for Payer: CORVEL All Commercial |
$99.28
|
| Rate for Payer: Coventry All Commercial |
$93.94
|
| Rate for Payer: Encore All Commercial |
$98.26
|
| Rate for Payer: Frontpath All Commercial |
$98.21
|
| Rate for Payer: Humana ChoiceCare |
$92.20
|
| Rate for Payer: Humana Medicare |
$54.44
|
| Rate for Payer: Lucent All Commercial |
$54.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.08
|
| Rate for Payer: PHCS All Commercial |
$80.06
|
| Rate for Payer: PHP All Commercial |
$80.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$41.63
|
| Rate for Payer: Sagamore Health Network All Products |
$82.41
|
| Rate for Payer: Signature Care EPO |
$88.60
|
| Rate for Payer: Signature Care PPO |
$93.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$90.74
|
| Rate for Payer: United Healthcare Commercial |
$84.12
|
| Rate for Payer: United Healthcare Medicare |
$35.23
|
|
|
DEXTROSE 50 % IN WATER (D50W) IV SYRG
|
Facility
|
IP
|
$106.75
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
114043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$99.28 |
| Rate for Payer: Aetna Commercial |
$92.23
|
| Rate for Payer: Cash Price |
$66.19
|
| Rate for Payer: Cigna All Commercial |
$92.13
|
| Rate for Payer: CORVEL All Commercial |
$99.28
|
| Rate for Payer: Coventry All Commercial |
$93.94
|
| Rate for Payer: Encore All Commercial |
$98.26
|
| Rate for Payer: Frontpath All Commercial |
$98.21
|
| Rate for Payer: Humana ChoiceCare |
$92.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$96.08
|
| Rate for Payer: PHCS All Commercial |
$80.06
|
| Rate for Payer: PHP All Commercial |
$80.96
|
| Rate for Payer: Sagamore Health Network All Products |
$82.41
|
| Rate for Payer: Signature Care EPO |
$88.60
|
| Rate for Payer: Signature Care PPO |
$93.94
|
| Rate for Payer: United Healthcare Commercial |
$84.12
|
|
|
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 |
$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
|
|
|
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 |
$9.24 |
| Max. Negotiated Rate |
$26.04 |
| Rate for Payer: Aetna Commercial |
$23.63
|
| Rate for Payer: Aetna Commercial |
$16.54
|
| Rate for Payer: Aetna Commercial |
$20.68
|
| Rate for Payer: Aetna Medicare |
$8.08
|
| Rate for Payer: Aetna Medicare |
$6.47
|
| Rate for Payer: Aetna Medicare |
$9.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.47
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.26
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.31
|
| 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: CareSource Indiana of IN Just 4 Me |
$9.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.16
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Cash Price |
$17.36
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: Centivo All Commercial |
$12.50
|
| Rate for Payer: Centivo All Commercial |
$14.28
|
| Rate for Payer: Centivo All Commercial |
$10.00
|
| Rate for Payer: Cigna All Commercial |
$24.16
|
| Rate for Payer: Cigna All Commercial |
$16.91
|
| Rate for Payer: Cigna All Commercial |
$21.14
|
| Rate for Payer: CORVEL All Commercial |
$26.04
|
| Rate for Payer: CORVEL All Commercial |
$18.23
|
| Rate for Payer: CORVEL All Commercial |
$22.78
|
| Rate for Payer: Coventry All Commercial |
$24.64
|
| Rate for Payer: Coventry All Commercial |
$17.25
|
| Rate for Payer: Coventry All Commercial |
$21.56
|
| Rate for Payer: Encore All Commercial |
$18.04
|
| Rate for Payer: Encore All Commercial |
$22.55
|
| Rate for Payer: Encore All Commercial |
$25.77
|
| Rate for Payer: Frontpath All Commercial |
$22.54
|
| Rate for Payer: Frontpath All Commercial |
$18.03
|
| Rate for Payer: Frontpath All Commercial |
$25.76
|
| Rate for Payer: Humana ChoiceCare |
$21.16
|
| Rate for Payer: Humana ChoiceCare |
$16.93
|
| Rate for Payer: Humana ChoiceCare |
$24.18
|
| Rate for Payer: Humana Medicare |
$12.50
|
| Rate for Payer: Humana Medicare |
$10.00
|
| Rate for Payer: Humana Medicare |
$14.28
|
| Rate for Payer: Lucent All Commercial |
$14.28
|
| Rate for Payer: Lucent All Commercial |
$10.00
|
| Rate for Payer: Lucent All Commercial |
$12.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.20
|
| Rate for Payer: PHCS All Commercial |
$14.70
|
| Rate for Payer: PHCS All Commercial |
$18.38
|
| Rate for Payer: PHCS All Commercial |
$21.00
|
| Rate for Payer: PHP All Commercial |
$21.24
|
| Rate for Payer: PHP All Commercial |
$14.86
|
| Rate for Payer: PHP All Commercial |
$18.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.64
|
| Rate for Payer: Sagamore Health Network All Products |
$18.91
|
| Rate for Payer: Sagamore Health Network All Products |
$15.13
|
| Rate for Payer: Sagamore Health Network All Products |
$21.62
|
| Rate for Payer: Signature Care EPO |
$20.34
|
| Rate for Payer: Signature Care EPO |
$16.27
|
| Rate for Payer: Signature Care EPO |
$23.24
|
| Rate for Payer: Signature Care PPO |
$17.25
|
| Rate for Payer: Signature Care PPO |
$21.56
|
| Rate for Payer: Signature Care PPO |
$24.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.66
|
| Rate for Payer: United Healthcare Commercial |
$19.31
|
| Rate for Payer: United Healthcare Commercial |
$15.44
|
| Rate for Payer: United Healthcare Commercial |
$22.06
|
| Rate for Payer: United Healthcare Medicare |
$8.08
|
| Rate for Payer: United Healthcare Medicare |
$9.24
|
| Rate for Payer: United Healthcare Medicare |
$6.47
|
|
|
DEXTROSE 5 % IN WATER (D5W) IV SOLP
|
Facility
|
IP
|
$24.50
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$18.38 |
| Max. Negotiated Rate |
$22.78 |
| Rate for Payer: Aetna Commercial |
$21.17
|
| Rate for Payer: Aetna Commercial |
$24.19
|
| Rate for Payer: Aetna Commercial |
$16.93
|
| Rate for Payer: Cash Price |
$17.36
|
| Rate for Payer: Cash Price |
$15.19
|
| Rate for Payer: Cash Price |
$12.15
|
| Rate for Payer: Cigna All Commercial |
$24.16
|
| Rate for Payer: Cigna All Commercial |
$16.91
|
| Rate for Payer: Cigna All Commercial |
$21.14
|
| Rate for Payer: CORVEL All Commercial |
$18.23
|
| Rate for Payer: CORVEL All Commercial |
$26.04
|
| Rate for Payer: CORVEL All Commercial |
$22.78
|
| Rate for Payer: Coventry All Commercial |
$17.25
|
| Rate for Payer: Coventry All Commercial |
$21.56
|
| Rate for Payer: Coventry All Commercial |
$24.64
|
| Rate for Payer: Encore All Commercial |
$22.55
|
| Rate for Payer: Encore All Commercial |
$25.77
|
| Rate for Payer: Encore All Commercial |
$18.04
|
| Rate for Payer: Frontpath All Commercial |
$25.76
|
| Rate for Payer: Frontpath All Commercial |
$18.03
|
| Rate for Payer: Frontpath All Commercial |
$22.54
|
| Rate for Payer: Humana ChoiceCare |
$16.93
|
| Rate for Payer: Humana ChoiceCare |
$24.18
|
| Rate for Payer: Humana ChoiceCare |
$21.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.64
|
| Rate for Payer: PHCS All Commercial |
$21.00
|
| Rate for Payer: PHCS All Commercial |
$14.70
|
| Rate for Payer: PHCS All Commercial |
$18.38
|
| Rate for Payer: PHP All Commercial |
$14.86
|
| Rate for Payer: PHP All Commercial |
$18.58
|
| Rate for Payer: PHP All Commercial |
$21.24
|
| Rate for Payer: Sagamore Health Network All Products |
$21.62
|
| Rate for Payer: Sagamore Health Network All Products |
$15.13
|
| Rate for Payer: Sagamore Health Network All Products |
$18.91
|
| Rate for Payer: Signature Care EPO |
$23.24
|
| Rate for Payer: Signature Care EPO |
$20.34
|
| Rate for Payer: Signature Care EPO |
$16.27
|
| Rate for Payer: Signature Care PPO |
$17.25
|
| Rate for Payer: Signature Care PPO |
$21.56
|
| Rate for Payer: Signature Care PPO |
$24.64
|
| Rate for Payer: United Healthcare Commercial |
$19.31
|
| Rate for Payer: United Healthcare Commercial |
$15.44
|
| Rate for Payer: United Healthcare Commercial |
$22.06
|
|
|
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 |
$13.86 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.25
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Centivo All Commercial |
$21.42
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Humana Medicare |
$21.42
|
| Rate for Payer: Lucent All Commercial |
$21.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.86
|
|
