|
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQD
|
Facility
|
OP
|
$31.40
|
|
|
Service Code
|
NDC 60687062850
|
| Hospital Charge Code |
6432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.73 |
| Max. Negotiated Rate |
$29.20 |
| Rate for Payer: Aetna Commercial |
$26.50
|
| Rate for Payer: Aetna Medicare |
$10.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$18.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.05
|
| Rate for Payer: Cash Price |
$18.84
|
| Rate for Payer: Centivo All Commercial |
$17.08
|
| Rate for Payer: Cigna All Commercial |
$27.09
|
| Rate for Payer: CORVEL All Commercial |
$29.20
|
| Rate for Payer: Coventry All Commercial |
$27.63
|
| Rate for Payer: Encore All Commercial |
$28.90
|
| Rate for Payer: Frontpath All Commercial |
$28.88
|
| Rate for Payer: Humana ChoiceCare |
$27.12
|
| Rate for Payer: Humana Medicare |
$10.05
|
| Rate for Payer: Lucent All Commercial |
$17.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.26
|
| Rate for Payer: PHCS All Commercial |
$23.55
|
| Rate for Payer: PHP All Commercial |
$23.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.24
|
| Rate for Payer: Sagamore Health Network All Products |
$24.24
|
| Rate for Payer: Signature Care EPO |
$26.06
|
| Rate for Payer: Signature Care PPO |
$27.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.69
|
| Rate for Payer: United Healthcare Commercial |
$24.74
|
| Rate for Payer: United Healthcare Medicare |
$10.05
|
|
|
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQD
|
Facility
|
IP
|
$24.99
|
|
|
Service Code
|
NDC 81033022015
|
| Hospital Charge Code |
6432
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.74 |
| Max. Negotiated Rate |
$23.24 |
| Rate for Payer: Aetna Commercial |
$21.59
|
| Rate for Payer: Cash Price |
$14.99
|
| Rate for Payer: Cigna All Commercial |
$21.57
|
| Rate for Payer: CORVEL All Commercial |
$23.24
|
| Rate for Payer: Coventry All Commercial |
$21.99
|
| Rate for Payer: Encore All Commercial |
$23.00
|
| Rate for Payer: Frontpath All Commercial |
$22.99
|
| Rate for Payer: Humana ChoiceCare |
$21.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.49
|
| Rate for Payer: PHCS All Commercial |
$18.74
|
| Rate for Payer: PHP All Commercial |
$18.95
|
| Rate for Payer: Sagamore Health Network All Products |
$19.29
|
| Rate for Payer: Signature Care EPO |
$20.74
|
| Rate for Payer: Signature Care PPO |
$21.99
|
| Rate for Payer: United Healthcare Commercial |
$19.69
|
|
|
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQD
|
Facility
|
OP
|
$24.99
|
|
|
Service Code
|
NDC 81033022015
|
| Hospital Charge Code |
6432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$23.24 |
| Rate for Payer: Aetna Commercial |
$21.09
|
| Rate for Payer: Aetna Medicare |
$8.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$14.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.80
|
| Rate for Payer: Cash Price |
$14.99
|
| Rate for Payer: Centivo All Commercial |
$13.59
|
| Rate for Payer: Cigna All Commercial |
$21.57
|
| Rate for Payer: CORVEL All Commercial |
$23.24
|
| Rate for Payer: Coventry All Commercial |
$21.99
|
| Rate for Payer: Encore All Commercial |
$23.00
|
| Rate for Payer: Frontpath All Commercial |
$22.99
|
| Rate for Payer: Humana ChoiceCare |
$21.58
|
| Rate for Payer: Humana Medicare |
$8.00
|
| Rate for Payer: Lucent All Commercial |
$13.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.49
|
| Rate for Payer: PHCS All Commercial |
$18.74
|
| Rate for Payer: PHP All Commercial |
$18.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.75
|
| Rate for Payer: Sagamore Health Network All Products |
$19.29
|
| Rate for Payer: Signature Care EPO |
$20.74
|
| Rate for Payer: Signature Care PPO |
$21.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.24
|
| Rate for Payer: United Healthcare Commercial |
$19.69
|
| Rate for Payer: United Healthcare Medicare |
$8.00
|
|
|
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQD
|
Facility
|
IP
|
$31.40
|
|
|
Service Code
|
NDC 60687062850
|
| Hospital Charge Code |
6432
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.55 |
| Max. Negotiated Rate |
$29.20 |
| Rate for Payer: Aetna Commercial |
$27.13
|
| Rate for Payer: Cash Price |
$18.84
|
| Rate for Payer: Cigna All Commercial |
$27.09
|
| Rate for Payer: CORVEL All Commercial |
$29.20
|
| Rate for Payer: Coventry All Commercial |
$27.63
|
| Rate for Payer: Encore All Commercial |
$28.90
|
| Rate for Payer: Frontpath All Commercial |
$28.88
|
| Rate for Payer: Humana ChoiceCare |
$27.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.26
|
| Rate for Payer: PHCS All Commercial |
$23.55
|
| Rate for Payer: PHP All Commercial |
$23.81
|
| Rate for Payer: Sagamore Health Network All Products |
$24.24
|
| Rate for Payer: Signature Care EPO |
$26.06
|
| Rate for Payer: Signature Care PPO |
$27.63
|
| Rate for Payer: United Healthcare Commercial |
$24.74
|
|
|
POTASSIUM CHLORIDE 20 MEQ ORAL TBTQ
|
Facility
|
IP
|
$3.14
|
|
|
Service Code
|
NDC 60687075609
|
| Hospital Charge Code |
35943
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Aetna Commercial |
$2.71
|
| Rate for Payer: Cash Price |
$1.88
|
| Rate for Payer: Cigna All Commercial |
$2.71
|
| Rate for Payer: CORVEL All Commercial |
$2.92
|
| Rate for Payer: Coventry All Commercial |
$2.76
|
| Rate for Payer: Encore All Commercial |
$2.89
|
| Rate for Payer: Frontpath All Commercial |
$2.89
|
| Rate for Payer: Humana ChoiceCare |
$2.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.82
|
| Rate for Payer: PHCS All Commercial |
$2.35
|
| Rate for Payer: PHP All Commercial |
$2.38
|
| Rate for Payer: Sagamore Health Network All Products |
$2.42
|
| Rate for Payer: Signature Care EPO |
$2.60
|
| Rate for Payer: Signature Care PPO |
$2.76
|
| Rate for Payer: United Healthcare Commercial |
$2.47
|
|
|
POTASSIUM CHLORIDE 20 MEQ ORAL TBTQ
|
Facility
|
OP
|
$3.14
|
|
|
Service Code
|
NDC 60687075611
|
| Hospital Charge Code |
35943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Aetna Commercial |
$2.65
|
| Rate for Payer: Aetna Medicare |
$1.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.10
|
| Rate for Payer: Cash Price |
$1.88
|
| Rate for Payer: Centivo All Commercial |
$1.71
|
| Rate for Payer: Cigna All Commercial |
$2.71
|
| Rate for Payer: CORVEL All Commercial |
$2.92
|
| Rate for Payer: Coventry All Commercial |
$2.76
|
| Rate for Payer: Encore All Commercial |
$2.89
|
| Rate for Payer: Frontpath All Commercial |
$2.89
|
| Rate for Payer: Humana ChoiceCare |
$2.71
|
| Rate for Payer: Humana Medicare |
$1.00
|
| Rate for Payer: Lucent All Commercial |
$1.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.82
|
| Rate for Payer: PHCS All Commercial |
$2.35
|
| Rate for Payer: PHP All Commercial |
$2.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.22
|
| Rate for Payer: Sagamore Health Network All Products |
$2.42
|
| Rate for Payer: Signature Care EPO |
$2.60
|
| Rate for Payer: Signature Care PPO |
$2.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.67
|
| Rate for Payer: United Healthcare Commercial |
$2.47
|
| Rate for Payer: United Healthcare Medicare |
$1.00
|
|
|
POTASSIUM CHLORIDE 20 MEQ ORAL TBTQ
|
Facility
|
OP
|
$3.14
|
|
|
Service Code
|
NDC 60687075609
|
| Hospital Charge Code |
35943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Aetna Commercial |
$2.65
|
| Rate for Payer: Aetna Medicare |
$1.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.10
|
| Rate for Payer: Cash Price |
$1.88
|
| Rate for Payer: Centivo All Commercial |
$1.71
|
| Rate for Payer: Cigna All Commercial |
$2.71
|
| Rate for Payer: CORVEL All Commercial |
$2.92
|
| Rate for Payer: Coventry All Commercial |
$2.76
|
| Rate for Payer: Encore All Commercial |
$2.89
|
| Rate for Payer: Frontpath All Commercial |
$2.89
|
| Rate for Payer: Humana ChoiceCare |
$2.71
|
| Rate for Payer: Humana Medicare |
$1.00
|
| Rate for Payer: Lucent All Commercial |
$1.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.82
|
| Rate for Payer: PHCS All Commercial |
$2.35
|
| Rate for Payer: PHP All Commercial |
$2.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.22
|
| Rate for Payer: Sagamore Health Network All Products |
$2.42
|
| Rate for Payer: Signature Care EPO |
$2.60
|
| Rate for Payer: Signature Care PPO |
$2.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.67
|
| Rate for Payer: United Healthcare Commercial |
$2.47
|
| Rate for Payer: United Healthcare Medicare |
$1.00
|
|
|
POTASSIUM CHLORIDE 20 MEQ ORAL TBTQ
|
Facility
|
IP
|
$3.14
|
|
|
Service Code
|
NDC 60687075611
|
| Hospital Charge Code |
35943
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Aetna Commercial |
$2.71
|
| Rate for Payer: Cash Price |
$1.88
|
| Rate for Payer: Cigna All Commercial |
$2.71
|
| Rate for Payer: CORVEL All Commercial |
$2.92
|
| Rate for Payer: Coventry All Commercial |
$2.76
|
| Rate for Payer: Encore All Commercial |
$2.89
|
| Rate for Payer: Frontpath All Commercial |
$2.89
|
| Rate for Payer: Humana ChoiceCare |
$2.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.82
|
| Rate for Payer: PHCS All Commercial |
$2.35
|
| Rate for Payer: PHP All Commercial |
$2.38
|
| Rate for Payer: Sagamore Health Network All Products |
$2.42
|
| Rate for Payer: Signature Care EPO |
$2.60
|
| Rate for Payer: Signature Care PPO |
$2.76
|
| Rate for Payer: United Healthcare Commercial |
$2.47
|
|
|
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN
|
Facility
|
OP
|
$64.12
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
6429
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.88 |
| Max. Negotiated Rate |
$59.63 |
| Rate for Payer: Aetna Commercial |
$54.12
|
| Rate for Payer: Aetna Medicare |
$20.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.88
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$36.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$40.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.57
|
| Rate for Payer: Cash Price |
$38.47
|
| Rate for Payer: Centivo All Commercial |
$34.88
|
| Rate for Payer: Cigna All Commercial |
$55.34
|
| Rate for Payer: CORVEL All Commercial |
$59.63
|
| Rate for Payer: Coventry All Commercial |
$56.43
|
| Rate for Payer: Encore All Commercial |
$59.02
|
| Rate for Payer: Frontpath All Commercial |
$58.99
|
| Rate for Payer: Humana ChoiceCare |
$55.38
|
| Rate for Payer: Humana Medicare |
$20.52
|
| Rate for Payer: Lucent All Commercial |
$34.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$57.71
|
| Rate for Payer: PHCS All Commercial |
$48.09
|
| Rate for Payer: PHP All Commercial |
$48.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$25.01
|
| Rate for Payer: Sagamore Health Network All Products |
$49.50
|
| Rate for Payer: Signature Care EPO |
$53.22
|
| Rate for Payer: Signature Care PPO |
$56.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$54.50
|
| Rate for Payer: United Healthcare Commercial |
$50.53
|
| Rate for Payer: United Healthcare Medicare |
$20.52
|
|
|
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN
|
Facility
|
IP
|
$64.12
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
6429
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.09 |
| Max. Negotiated Rate |
$59.63 |
| Rate for Payer: Aetna Commercial |
$55.40
|
| Rate for Payer: Cash Price |
$38.47
|
| Rate for Payer: Cigna All Commercial |
$55.34
|
| Rate for Payer: CORVEL All Commercial |
$59.63
|
| Rate for Payer: Coventry All Commercial |
$56.43
|
| Rate for Payer: Encore All Commercial |
$59.02
|
| Rate for Payer: Frontpath All Commercial |
$58.99
|
| Rate for Payer: Humana ChoiceCare |
$55.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$57.71
|
| Rate for Payer: PHCS All Commercial |
$48.09
|
| Rate for Payer: PHP All Commercial |
$48.63
|
| Rate for Payer: Sagamore Health Network All Products |
$49.50
|
| Rate for Payer: Signature Care EPO |
$53.22
|
| Rate for Payer: Signature Care PPO |
$56.43
|
| Rate for Payer: United Healthcare Commercial |
$50.53
|
|
|
POTASSIUM CHLORIDE-D5-0.9%NACL 20 MEQ/L IV SOLP
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
9795
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.75 |
| Max. Negotiated Rate |
$71.61 |
| Rate for Payer: Aetna Commercial |
$66.53
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna All Commercial |
$66.45
|
| Rate for Payer: CORVEL All Commercial |
$71.61
|
| Rate for Payer: Coventry All Commercial |
$67.76
|
| Rate for Payer: Encore All Commercial |
$70.88
|
| Rate for Payer: Frontpath All Commercial |
$70.84
|
| Rate for Payer: Humana ChoiceCare |
$66.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$69.30
|
| Rate for Payer: PHCS All Commercial |
$57.75
|
| Rate for Payer: PHP All Commercial |
$58.40
|
| Rate for Payer: Sagamore Health Network All Products |
$59.44
|
| Rate for Payer: Signature Care EPO |
$63.91
|
| Rate for Payer: Signature Care PPO |
$67.76
|
| Rate for Payer: United Healthcare Commercial |
$60.68
|
|
|
POTASSIUM CHLORIDE-D5-0.9%NACL 20 MEQ/L IV SOLP
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
9795
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.87 |
| Max. Negotiated Rate |
$71.61 |
| Rate for Payer: Aetna Commercial |
$64.99
|
| Rate for Payer: Aetna Medicare |
$24.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$23.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$44.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$48.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$28.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.10
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Centivo All Commercial |
$41.89
|
| Rate for Payer: Cigna All Commercial |
$66.45
|
| Rate for Payer: CORVEL All Commercial |
$71.61
|
| Rate for Payer: Coventry All Commercial |
$67.76
|
| Rate for Payer: Encore All Commercial |
$70.88
|
| Rate for Payer: Frontpath All Commercial |
$70.84
|
| Rate for Payer: Humana ChoiceCare |
$66.50
|
| Rate for Payer: Humana Medicare |
$24.64
|
| Rate for Payer: Lucent All Commercial |
$41.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$69.30
|
| Rate for Payer: PHCS All Commercial |
$57.75
|
| Rate for Payer: PHP All Commercial |
$58.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$30.03
|
| Rate for Payer: Sagamore Health Network All Products |
$59.44
|
| Rate for Payer: Signature Care EPO |
$63.91
|
| Rate for Payer: Signature Care PPO |
$67.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$65.45
|
| Rate for Payer: United Healthcare Commercial |
$60.68
|
| Rate for Payer: United Healthcare Medicare |
$24.64
|
|
|
POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML IV PGBK
|
Facility
|
OP
|
$37.10
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: Aetna Commercial |
$31.31
|
| Rate for Payer: Aetna Medicare |
$11.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$21.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.06
|
| Rate for Payer: Cash Price |
$22.26
|
| Rate for Payer: Centivo All Commercial |
$20.18
|
| Rate for Payer: Cigna All Commercial |
$32.02
|
| Rate for Payer: CORVEL All Commercial |
$34.50
|
| Rate for Payer: Coventry All Commercial |
$32.65
|
| Rate for Payer: Encore All Commercial |
$34.15
|
| Rate for Payer: Frontpath All Commercial |
$34.13
|
| Rate for Payer: Humana ChoiceCare |
$32.04
|
| Rate for Payer: Humana Medicare |
$11.87
|
| Rate for Payer: Lucent All Commercial |
$20.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.39
|
| Rate for Payer: PHCS All Commercial |
$27.82
|
| Rate for Payer: PHP All Commercial |
$28.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.47
|
| Rate for Payer: Sagamore Health Network All Products |
$28.64
|
| Rate for Payer: Signature Care EPO |
$30.79
|
| Rate for Payer: Signature Care PPO |
$32.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.54
|
| Rate for Payer: United Healthcare Commercial |
$29.23
|
| Rate for Payer: United Healthcare Medicare |
$11.87
|
|
|
POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML IV PGBK
|
Facility
|
IP
|
$37.10
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11076
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.82 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: Aetna Commercial |
$32.05
|
| Rate for Payer: Cash Price |
$22.26
|
| Rate for Payer: Cigna All Commercial |
$32.02
|
| Rate for Payer: CORVEL All Commercial |
$34.50
|
| Rate for Payer: Coventry All Commercial |
$32.65
|
| Rate for Payer: Encore All Commercial |
$34.15
|
| Rate for Payer: Frontpath All Commercial |
$34.13
|
| Rate for Payer: Humana ChoiceCare |
$32.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.39
|
| Rate for Payer: PHCS All Commercial |
$27.82
|
| Rate for Payer: PHP All Commercial |
$28.14
|
| Rate for Payer: Sagamore Health Network All Products |
$28.64
|
| Rate for Payer: Signature Care EPO |
$30.79
|
| Rate for Payer: Signature Care PPO |
$32.65
|
| Rate for Payer: United Healthcare Commercial |
$29.23
|
|
|
POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML IV PGBK (CAMERON)
|
Facility
|
IP
|
$37.10
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
14011076
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.82 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: Aetna Commercial |
$32.05
|
| Rate for Payer: Cash Price |
$22.26
|
| Rate for Payer: Cigna All Commercial |
$32.02
|
| Rate for Payer: CORVEL All Commercial |
$34.50
|
| Rate for Payer: Coventry All Commercial |
$32.65
|
| Rate for Payer: Encore All Commercial |
$34.15
|
| Rate for Payer: Frontpath All Commercial |
$34.13
|
| Rate for Payer: Humana ChoiceCare |
$32.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.39
|
| Rate for Payer: PHCS All Commercial |
$27.82
|
| Rate for Payer: PHP All Commercial |
$28.14
|
| Rate for Payer: Sagamore Health Network All Products |
$28.64
|
| Rate for Payer: Signature Care EPO |
$30.79
|
| Rate for Payer: Signature Care PPO |
$32.65
|
| Rate for Payer: United Healthcare Commercial |
$29.23
|
|
|
POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML IV PGBK (CAMERON)
|
Facility
|
OP
|
$37.10
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
14011076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: Aetna Commercial |
$31.31
|
| Rate for Payer: Aetna Medicare |
$11.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$21.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.06
|
| Rate for Payer: Cash Price |
$22.26
|
| Rate for Payer: Centivo All Commercial |
$20.18
|
| Rate for Payer: Cigna All Commercial |
$32.02
|
| Rate for Payer: CORVEL All Commercial |
$34.50
|
| Rate for Payer: Coventry All Commercial |
$32.65
|
| Rate for Payer: Encore All Commercial |
$34.15
|
| Rate for Payer: Frontpath All Commercial |
$34.13
|
| Rate for Payer: Humana ChoiceCare |
$32.04
|
| Rate for Payer: Humana Medicare |
$11.87
|
| Rate for Payer: Lucent All Commercial |
$20.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.39
|
| Rate for Payer: PHCS All Commercial |
$27.82
|
| Rate for Payer: PHP All Commercial |
$28.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.47
|
| Rate for Payer: Sagamore Health Network All Products |
$28.64
|
| Rate for Payer: Signature Care EPO |
$30.79
|
| Rate for Payer: Signature Care PPO |
$32.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.54
|
| Rate for Payer: United Healthcare Commercial |
$29.23
|
| Rate for Payer: United Healthcare Medicare |
$11.87
|
|
|
POTASSIUM CHLORIDE IN WATER 40 MEQ/100 ML IV PGBK
|
Facility
|
OP
|
$27.30
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11079
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$25.39 |
| Rate for Payer: Aetna Commercial |
$23.04
|
| Rate for Payer: Aetna Medicare |
$8.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$15.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.61
|
| Rate for Payer: Cash Price |
$16.38
|
| Rate for Payer: Centivo All Commercial |
$14.85
|
| Rate for Payer: Cigna All Commercial |
$23.56
|
| Rate for Payer: CORVEL All Commercial |
$25.39
|
| Rate for Payer: Coventry All Commercial |
$24.02
|
| Rate for Payer: Encore All Commercial |
$25.13
|
| Rate for Payer: Frontpath All Commercial |
$25.12
|
| Rate for Payer: Humana ChoiceCare |
$23.58
|
| Rate for Payer: Humana Medicare |
$8.74
|
| Rate for Payer: Lucent All Commercial |
$14.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.57
|
| Rate for Payer: PHCS All Commercial |
$20.48
|
| Rate for Payer: PHP All Commercial |
$20.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.65
|
| Rate for Payer: Sagamore Health Network All Products |
$21.08
|
| Rate for Payer: Signature Care EPO |
$22.66
|
| Rate for Payer: Signature Care PPO |
$24.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.20
|
| Rate for Payer: United Healthcare Commercial |
$21.51
|
| Rate for Payer: United Healthcare Medicare |
$8.74
|
|
|
POTASSIUM CHLORIDE IN WATER 40 MEQ/100 ML IV PGBK
|
Facility
|
IP
|
$27.30
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11079
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$25.39 |
| Rate for Payer: Aetna Commercial |
$23.59
|
| Rate for Payer: Cash Price |
$16.38
|
| Rate for Payer: Cigna All Commercial |
$23.56
|
| Rate for Payer: CORVEL All Commercial |
$25.39
|
| Rate for Payer: Coventry All Commercial |
$24.02
|
| Rate for Payer: Encore All Commercial |
$25.13
|
| Rate for Payer: Frontpath All Commercial |
$25.12
|
| Rate for Payer: Humana ChoiceCare |
$23.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.57
|
| Rate for Payer: PHCS All Commercial |
$20.48
|
| Rate for Payer: PHP All Commercial |
$20.70
|
| Rate for Payer: Sagamore Health Network All Products |
$21.08
|
| Rate for Payer: Signature Care EPO |
$22.66
|
| Rate for Payer: Signature Care PPO |
$24.02
|
| Rate for Payer: United Healthcare Commercial |
$21.51
|
|
|
POTASSIUM CHLORIDE IN WATER 40 MEQ/100 ML IV PGBK (CAMERON)
|
Facility
|
IP
|
$27.30
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
14011079
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$25.39 |
| Rate for Payer: Aetna Commercial |
$23.59
|
| Rate for Payer: Cash Price |
$16.38
|
| Rate for Payer: Cigna All Commercial |
$23.56
|
| Rate for Payer: CORVEL All Commercial |
$25.39
|
| Rate for Payer: Coventry All Commercial |
$24.02
|
| Rate for Payer: Encore All Commercial |
$25.13
|
| Rate for Payer: Frontpath All Commercial |
$25.12
|
| Rate for Payer: Humana ChoiceCare |
$23.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.57
|
| Rate for Payer: PHCS All Commercial |
$20.48
|
| Rate for Payer: PHP All Commercial |
$20.70
|
| Rate for Payer: Sagamore Health Network All Products |
$21.08
|
| Rate for Payer: Signature Care EPO |
$22.66
|
| Rate for Payer: Signature Care PPO |
$24.02
|
| Rate for Payer: United Healthcare Commercial |
$21.51
|
|
|
POTASSIUM CHLORIDE IN WATER 40 MEQ/100 ML IV PGBK (CAMERON)
|
Facility
|
OP
|
$27.30
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
14011079
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$25.39 |
| Rate for Payer: Aetna Commercial |
$23.04
|
| Rate for Payer: Aetna Medicare |
$8.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$15.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.61
|
| Rate for Payer: Cash Price |
$16.38
|
| Rate for Payer: Centivo All Commercial |
$14.85
|
| Rate for Payer: Cigna All Commercial |
$23.56
|
| Rate for Payer: CORVEL All Commercial |
$25.39
|
| Rate for Payer: Coventry All Commercial |
$24.02
|
| Rate for Payer: Encore All Commercial |
$25.13
|
| Rate for Payer: Frontpath All Commercial |
$25.12
|
| Rate for Payer: Humana ChoiceCare |
$23.58
|
| Rate for Payer: Humana Medicare |
$8.74
|
| Rate for Payer: Lucent All Commercial |
$14.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.57
|
| Rate for Payer: PHCS All Commercial |
$20.48
|
| Rate for Payer: PHP All Commercial |
$20.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.65
|
| Rate for Payer: Sagamore Health Network All Products |
$21.08
|
| Rate for Payer: Signature Care EPO |
$22.66
|
| Rate for Payer: Signature Care PPO |
$24.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.20
|
| Rate for Payer: United Healthcare Commercial |
$21.51
|
| Rate for Payer: United Healthcare Medicare |
$8.74
|
|
|
POTASSIUM IODIDE 130 MG ORAL TAB
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 51803000110
|
| Hospital Charge Code |
13024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
POTASSIUM IODIDE 130 MG ORAL TAB
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 51803000110
|
| Hospital Charge Code |
13024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
POTASSIUM PHOSPHATE M-/D-BASIC 3 MMOL/ML IV SOLN
|
Facility
|
IP
|
$103.53
|
|
|
Service Code
|
NDC 00409729501
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.65 |
| Max. Negotiated Rate |
$96.28 |
| Rate for Payer: Aetna Commercial |
$89.45
|
| Rate for Payer: Cash Price |
$62.12
|
| Rate for Payer: Cigna All Commercial |
$89.35
|
| Rate for Payer: CORVEL All Commercial |
$96.28
|
| Rate for Payer: Coventry All Commercial |
$91.11
|
| Rate for Payer: Encore All Commercial |
$95.30
|
| Rate for Payer: Frontpath All Commercial |
$95.25
|
| Rate for Payer: Humana ChoiceCare |
$89.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$93.18
|
| Rate for Payer: PHCS All Commercial |
$77.65
|
| Rate for Payer: PHP All Commercial |
$78.52
|
| Rate for Payer: Sagamore Health Network All Products |
$79.93
|
| Rate for Payer: Signature Care EPO |
$85.93
|
| Rate for Payer: Signature Care PPO |
$91.11
|
| Rate for Payer: United Healthcare Commercial |
$81.58
|
|
|
POTASSIUM PHOSPHATE M-/D-BASIC 3 MMOL/ML IV SOLN
|
Facility
|
OP
|
$103.53
|
|
|
Service Code
|
NDC 00409729501
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$96.28 |
| Rate for Payer: Aetna Commercial |
$87.38
|
| Rate for Payer: Aetna Medicare |
$33.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$32.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$59.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$64.72
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$38.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.44
|
| Rate for Payer: Cash Price |
$62.12
|
| Rate for Payer: Cash Price |
$62.12
|
| Rate for Payer: Centivo All Commercial |
$56.32
|
| Rate for Payer: Cigna All Commercial |
$89.35
|
| Rate for Payer: CORVEL All Commercial |
$96.28
|
| Rate for Payer: Coventry All Commercial |
$91.11
|
| Rate for Payer: Encore All Commercial |
$95.30
|
| Rate for Payer: Frontpath All Commercial |
$95.25
|
| Rate for Payer: Humana ChoiceCare |
$89.42
|
| Rate for Payer: Humana Medicare |
$33.13
|
| Rate for Payer: Lucent All Commercial |
$56.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$93.18
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$77.65
|
| Rate for Payer: PHP All Commercial |
$78.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.38
|
| Rate for Payer: Sagamore Health Network All Products |
$79.93
|
| Rate for Payer: Signature Care EPO |
$85.93
|
| Rate for Payer: Signature Care PPO |
$91.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$88.00
|
| Rate for Payer: United Healthcare Commercial |
$81.58
|
| Rate for Payer: United Healthcare Medicare |
$33.13
|
|
|
POVIDONE-IODINE 10 % TOP SOLN
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 00395232516
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
|
