|
SOD BORATE-BORIC AC-NACL-WATER OPHT IRSL
|
Facility
|
IP
|
$29.74
|
|
|
Service Code
|
NDC 10119000252
|
| Hospital Charge Code |
163510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.30 |
| Max. Negotiated Rate |
$27.65 |
| Rate for Payer: Aetna Commercial |
$25.69
|
| Rate for Payer: Cash Price |
$18.44
|
| Rate for Payer: Cigna All Commercial |
$25.66
|
| Rate for Payer: CORVEL All Commercial |
$27.65
|
| Rate for Payer: Coventry All Commercial |
$26.17
|
| Rate for Payer: Encore All Commercial |
$27.37
|
| Rate for Payer: Frontpath All Commercial |
$27.36
|
| Rate for Payer: Humana ChoiceCare |
$25.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.76
|
| Rate for Payer: PHCS All Commercial |
$22.30
|
| Rate for Payer: PHP All Commercial |
$22.55
|
| Rate for Payer: Sagamore Health Network All Products |
$22.96
|
| Rate for Payer: Signature Care EPO |
$24.68
|
| Rate for Payer: Signature Care PPO |
$26.17
|
| Rate for Payer: United Healthcare Commercial |
$23.43
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) IV SOLN
|
Facility
|
IP
|
$56.35
|
|
|
Service Code
|
NDC 00409662514
|
| Hospital Charge Code |
111015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.26 |
| Max. Negotiated Rate |
$52.41 |
| Rate for Payer: Aetna Commercial |
$48.69
|
| Rate for Payer: Cash Price |
$34.94
|
| Rate for Payer: Cigna All Commercial |
$48.63
|
| Rate for Payer: CORVEL All Commercial |
$52.41
|
| Rate for Payer: Coventry All Commercial |
$49.59
|
| Rate for Payer: Encore All Commercial |
$51.87
|
| Rate for Payer: Frontpath All Commercial |
$51.84
|
| Rate for Payer: Humana ChoiceCare |
$48.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$50.72
|
| Rate for Payer: PHCS All Commercial |
$42.26
|
| Rate for Payer: PHP All Commercial |
$42.74
|
| Rate for Payer: Sagamore Health Network All Products |
$43.50
|
| Rate for Payer: Signature Care EPO |
$46.77
|
| Rate for Payer: Signature Care PPO |
$49.59
|
| Rate for Payer: United Healthcare Commercial |
$44.40
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) IV SOLN
|
Facility
|
OP
|
$56.35
|
|
|
Service Code
|
NDC 00409662514
|
| Hospital Charge Code |
111015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$52.41 |
| Rate for Payer: Aetna Commercial |
$47.56
|
| Rate for Payer: Aetna Medicare |
$18.03
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$32.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$35.22
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$20.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.84
|
| Rate for Payer: Cash Price |
$34.94
|
| Rate for Payer: Cash Price |
$34.94
|
| Rate for Payer: Centivo All Commercial |
$30.65
|
| Rate for Payer: Cigna All Commercial |
$48.63
|
| Rate for Payer: CORVEL All Commercial |
$52.41
|
| Rate for Payer: Coventry All Commercial |
$49.59
|
| Rate for Payer: Encore All Commercial |
$51.87
|
| Rate for Payer: Frontpath All Commercial |
$51.84
|
| Rate for Payer: Humana ChoiceCare |
$48.67
|
| Rate for Payer: Humana Medicare |
$18.03
|
| Rate for Payer: Lucent All Commercial |
$30.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$50.72
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$42.26
|
| Rate for Payer: PHP All Commercial |
$42.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$21.98
|
| Rate for Payer: Sagamore Health Network All Products |
$43.50
|
| Rate for Payer: Signature Care EPO |
$46.77
|
| Rate for Payer: Signature Care PPO |
$49.59
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$47.90
|
| Rate for Payer: United Healthcare Commercial |
$44.40
|
| Rate for Payer: United Healthcare Medicare |
$18.03
|
|
|
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) IV SYRG
|
Facility
|
IP
|
$117.95
|
|
|
Service Code
|
NDC 00409553414
|
| Hospital Charge Code |
7306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.46 |
| Max. Negotiated Rate |
$109.69 |
| Rate for Payer: Aetna Commercial |
$101.91
|
| Rate for Payer: Cash Price |
$73.13
|
| Rate for Payer: Cigna All Commercial |
$101.79
|
| Rate for Payer: CORVEL All Commercial |
$109.69
|
| Rate for Payer: Coventry All Commercial |
$103.80
|
| Rate for Payer: Encore All Commercial |
$108.57
|
| Rate for Payer: Frontpath All Commercial |
$108.51
|
| Rate for Payer: Humana ChoiceCare |
$101.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$106.16
|
| Rate for Payer: PHCS All Commercial |
$88.46
|
| Rate for Payer: PHP All Commercial |
$89.45
|
| Rate for Payer: Sagamore Health Network All Products |
$91.06
|
| Rate for Payer: Signature Care EPO |
$97.90
|
| Rate for Payer: Signature Care PPO |
$103.80
|
| Rate for Payer: United Healthcare Commercial |
$92.94
|
|
|
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) IV SYRG
|
Facility
|
OP
|
$117.95
|
|
|
Service Code
|
NDC 00409553414
|
| Hospital Charge Code |
7306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$109.69 |
| Rate for Payer: Aetna Commercial |
$99.55
|
| Rate for Payer: Aetna Medicare |
$37.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$36.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$67.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$73.73
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$43.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$41.52
|
| Rate for Payer: Cash Price |
$73.13
|
| Rate for Payer: Cash Price |
$73.13
|
| Rate for Payer: Centivo All Commercial |
$64.16
|
| Rate for Payer: Cigna All Commercial |
$101.79
|
| Rate for Payer: CORVEL All Commercial |
$109.69
|
| Rate for Payer: Coventry All Commercial |
$103.80
|
| Rate for Payer: Encore All Commercial |
$108.57
|
| Rate for Payer: Frontpath All Commercial |
$108.51
|
| Rate for Payer: Humana ChoiceCare |
$101.87
|
| Rate for Payer: Humana Medicare |
$37.74
|
| Rate for Payer: Lucent All Commercial |
$64.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$106.16
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$88.46
|
| Rate for Payer: PHP All Commercial |
$89.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$46.00
|
| Rate for Payer: Sagamore Health Network All Products |
$91.06
|
| Rate for Payer: Signature Care EPO |
$97.90
|
| Rate for Payer: Signature Care PPO |
$103.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$100.26
|
| Rate for Payer: United Healthcare Commercial |
$92.94
|
| Rate for Payer: United Healthcare Medicare |
$37.74
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
IP
|
$154.35
|
|
|
Service Code
|
NDC 63323008305
|
| Hospital Charge Code |
111085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$115.76 |
| Max. Negotiated Rate |
$143.55 |
| Rate for Payer: Aetna Commercial |
$133.36
|
| Rate for Payer: Cash Price |
$95.70
|
| Rate for Payer: Cigna All Commercial |
$133.20
|
| Rate for Payer: CORVEL All Commercial |
$143.55
|
| Rate for Payer: Coventry All Commercial |
$135.83
|
| Rate for Payer: Encore All Commercial |
$142.08
|
| Rate for Payer: Frontpath All Commercial |
$142.00
|
| Rate for Payer: Humana ChoiceCare |
$133.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$138.91
|
| Rate for Payer: PHCS All Commercial |
$115.76
|
| Rate for Payer: PHP All Commercial |
$117.06
|
| Rate for Payer: Sagamore Health Network All Products |
$119.16
|
| Rate for Payer: Signature Care EPO |
$128.11
|
| Rate for Payer: Signature Care PPO |
$135.83
|
| Rate for Payer: United Healthcare Commercial |
$121.63
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
OP
|
$154.35
|
|
|
Service Code
|
NDC 63323008305
|
| Hospital Charge Code |
111085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$143.55 |
| Rate for Payer: Aetna Commercial |
$130.27
|
| Rate for Payer: Aetna Medicare |
$49.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$47.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$88.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$96.48
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$56.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$54.33
|
| Rate for Payer: Cash Price |
$95.70
|
| Rate for Payer: Cash Price |
$95.70
|
| Rate for Payer: Centivo All Commercial |
$83.97
|
| Rate for Payer: Cigna All Commercial |
$133.20
|
| Rate for Payer: CORVEL All Commercial |
$143.55
|
| Rate for Payer: Coventry All Commercial |
$135.83
|
| Rate for Payer: Encore All Commercial |
$142.08
|
| Rate for Payer: Frontpath All Commercial |
$142.00
|
| Rate for Payer: Humana ChoiceCare |
$133.31
|
| Rate for Payer: Humana Medicare |
$49.39
|
| Rate for Payer: Lucent All Commercial |
$83.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$138.91
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$115.76
|
| Rate for Payer: PHP All Commercial |
$117.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$60.20
|
| Rate for Payer: Sagamore Health Network All Products |
$119.16
|
| Rate for Payer: Signature Care EPO |
$128.11
|
| Rate for Payer: Signature Care PPO |
$135.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$131.20
|
| Rate for Payer: United Healthcare Commercial |
$121.63
|
| Rate for Payer: United Healthcare Medicare |
$49.39
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN S.O. (CAMERON)
|
Facility
|
IP
|
$63.21
|
|
|
Service Code
|
NDC 51754501201
|
| Hospital Charge Code |
140111085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.41 |
| Max. Negotiated Rate |
$58.79 |
| Rate for Payer: Aetna Commercial |
$54.61
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna All Commercial |
$54.55
|
| Rate for Payer: CORVEL All Commercial |
$58.79
|
| Rate for Payer: Coventry All Commercial |
$55.62
|
| Rate for Payer: Encore All Commercial |
$58.18
|
| Rate for Payer: Frontpath All Commercial |
$58.15
|
| Rate for Payer: Humana ChoiceCare |
$54.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.89
|
| Rate for Payer: PHCS All Commercial |
$47.41
|
| Rate for Payer: PHP All Commercial |
$47.94
|
| Rate for Payer: Sagamore Health Network All Products |
$48.80
|
| Rate for Payer: Signature Care EPO |
$52.46
|
| Rate for Payer: Signature Care PPO |
$55.62
|
| Rate for Payer: United Healthcare Commercial |
$49.81
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN S.O. (CAMERON)
|
Facility
|
OP
|
$63.21
|
|
|
Service Code
|
NDC 51754501201
|
| Hospital Charge Code |
140111085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$58.79 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Medicare |
$20.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$36.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.51
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.25
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Centivo All Commercial |
$34.39
|
| Rate for Payer: Cigna All Commercial |
$54.55
|
| Rate for Payer: CORVEL All Commercial |
$58.79
|
| Rate for Payer: Coventry All Commercial |
$55.62
|
| Rate for Payer: Encore All Commercial |
$58.18
|
| Rate for Payer: Frontpath All Commercial |
$58.15
|
| Rate for Payer: Humana ChoiceCare |
$54.59
|
| Rate for Payer: Humana Medicare |
$20.23
|
| Rate for Payer: Lucent All Commercial |
$34.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.89
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$47.41
|
| Rate for Payer: PHP All Commercial |
$47.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.65
|
| Rate for Payer: Sagamore Health Network All Products |
$48.80
|
| Rate for Payer: Signature Care EPO |
$52.46
|
| Rate for Payer: Signature Care PPO |
$55.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$53.73
|
| Rate for Payer: United Healthcare Commercial |
$49.81
|
| Rate for Payer: United Healthcare Medicare |
$20.23
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN S.O. (CAMERON)
|
Facility
|
OP
|
$63.21
|
|
|
Service Code
|
NDC 51754501204
|
| Hospital Charge Code |
140111085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$58.79 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Medicare |
$20.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$36.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.51
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.25
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Centivo All Commercial |
$34.39
|
| Rate for Payer: Cigna All Commercial |
$54.55
|
| Rate for Payer: CORVEL All Commercial |
$58.79
|
| Rate for Payer: Coventry All Commercial |
$55.62
|
| Rate for Payer: Encore All Commercial |
$58.18
|
| Rate for Payer: Frontpath All Commercial |
$58.15
|
| Rate for Payer: Humana ChoiceCare |
$54.59
|
| Rate for Payer: Humana Medicare |
$20.23
|
| Rate for Payer: Lucent All Commercial |
$34.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.89
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$47.41
|
| Rate for Payer: PHP All Commercial |
$47.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.65
|
| Rate for Payer: Sagamore Health Network All Products |
$48.80
|
| Rate for Payer: Signature Care EPO |
$52.46
|
| Rate for Payer: Signature Care PPO |
$55.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$53.73
|
| Rate for Payer: United Healthcare Commercial |
$49.81
|
| Rate for Payer: United Healthcare Medicare |
$20.23
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN S.O. (CAMERON)
|
Facility
|
IP
|
$63.21
|
|
|
Service Code
|
NDC 51754501204
|
| Hospital Charge Code |
140111085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.41 |
| Max. Negotiated Rate |
$58.79 |
| Rate for Payer: Aetna Commercial |
$54.61
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna All Commercial |
$54.55
|
| Rate for Payer: CORVEL All Commercial |
$58.79
|
| Rate for Payer: Coventry All Commercial |
$55.62
|
| Rate for Payer: Encore All Commercial |
$58.18
|
| Rate for Payer: Frontpath All Commercial |
$58.15
|
| Rate for Payer: Humana ChoiceCare |
$54.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.89
|
| Rate for Payer: PHCS All Commercial |
$47.41
|
| Rate for Payer: PHP All Commercial |
$47.94
|
| Rate for Payer: Sagamore Health Network All Products |
$48.80
|
| Rate for Payer: Signature Care EPO |
$52.46
|
| Rate for Payer: Signature Care PPO |
$55.62
|
| Rate for Payer: United Healthcare Commercial |
$49.81
|
|
|
SODIUM BICARBONATE 650 MG ORAL TAB
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 00904726161
|
| Hospital Charge Code |
7312
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna Commercial |
$0.82
|
| Rate for Payer: Aetna Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.34
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.53
|
| Rate for Payer: Cigna All Commercial |
$0.83
|
| Rate for Payer: CORVEL All Commercial |
$0.90
|
| Rate for Payer: Coventry All Commercial |
$0.85
|
| Rate for Payer: Encore All Commercial |
$0.89
|
| Rate for Payer: Frontpath All Commercial |
$0.89
|
| Rate for Payer: Humana ChoiceCare |
$0.83
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Lucent All Commercial |
$0.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.87
|
| Rate for Payer: PHCS All Commercial |
$0.72
|
| Rate for Payer: PHP All Commercial |
$0.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.38
|
| Rate for Payer: Sagamore Health Network All Products |
$0.75
|
| Rate for Payer: Signature Care EPO |
$0.80
|
| Rate for Payer: Signature Care PPO |
$0.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$0.76
|
| Rate for Payer: United Healthcare Medicare |
$0.31
|
|
|
SODIUM BICARBONATE 650 MG ORAL TAB
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 00904726161
|
| Hospital Charge Code |
7312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna Commercial |
$0.83
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.83
|
| Rate for Payer: CORVEL All Commercial |
$0.90
|
| Rate for Payer: Coventry All Commercial |
$0.85
|
| Rate for Payer: Encore All Commercial |
$0.89
|
| Rate for Payer: Frontpath All Commercial |
$0.89
|
| Rate for Payer: Humana ChoiceCare |
$0.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.87
|
| Rate for Payer: PHCS All Commercial |
$0.72
|
| Rate for Payer: PHP All Commercial |
$0.73
|
| Rate for Payer: Sagamore Health Network All Products |
$0.75
|
| Rate for Payer: Signature Care EPO |
$0.80
|
| Rate for Payer: Signature Care PPO |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.76
|
|
|
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRG
|
Facility
|
IP
|
$117.25
|
|
|
Service Code
|
NDC 76329335201
|
| Hospital Charge Code |
7309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.94 |
| Max. Negotiated Rate |
$109.04 |
| Rate for Payer: Aetna Commercial |
$101.30
|
| Rate for Payer: Cash Price |
$72.70
|
| Rate for Payer: Cigna All Commercial |
$101.19
|
| Rate for Payer: CORVEL All Commercial |
$109.04
|
| Rate for Payer: Coventry All Commercial |
$103.18
|
| Rate for Payer: Encore All Commercial |
$107.93
|
| Rate for Payer: Frontpath All Commercial |
$107.87
|
| Rate for Payer: Humana ChoiceCare |
$101.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$105.53
|
| Rate for Payer: PHCS All Commercial |
$87.94
|
| Rate for Payer: PHP All Commercial |
$88.92
|
| Rate for Payer: Sagamore Health Network All Products |
$90.52
|
| Rate for Payer: Signature Care EPO |
$97.32
|
| Rate for Payer: Signature Care PPO |
$103.18
|
| Rate for Payer: United Healthcare Commercial |
$92.39
|
|
|
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRG
|
Facility
|
OP
|
$117.25
|
|
|
Service Code
|
NDC 76329335201
|
| Hospital Charge Code |
7309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$109.04 |
| Rate for Payer: Aetna Commercial |
$98.96
|
| Rate for Payer: Aetna Medicare |
$37.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$36.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$67.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$73.29
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$43.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$41.27
|
| Rate for Payer: Cash Price |
$72.70
|
| Rate for Payer: Cash Price |
$72.70
|
| Rate for Payer: Centivo All Commercial |
$63.78
|
| Rate for Payer: Cigna All Commercial |
$101.19
|
| Rate for Payer: CORVEL All Commercial |
$109.04
|
| Rate for Payer: Coventry All Commercial |
$103.18
|
| Rate for Payer: Encore All Commercial |
$107.93
|
| Rate for Payer: Frontpath All Commercial |
$107.87
|
| Rate for Payer: Humana ChoiceCare |
$101.27
|
| Rate for Payer: Humana Medicare |
$37.52
|
| Rate for Payer: Lucent All Commercial |
$63.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$105.53
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$87.94
|
| Rate for Payer: PHP All Commercial |
$88.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$45.73
|
| Rate for Payer: Sagamore Health Network All Products |
$90.52
|
| Rate for Payer: Signature Care EPO |
$97.32
|
| Rate for Payer: Signature Care PPO |
$103.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$99.66
|
| Rate for Payer: United Healthcare Commercial |
$92.39
|
| Rate for Payer: United Healthcare Medicare |
$37.52
|
|
|
SODIUM CHLOR 0.9% BACTERIOSTAT 0.9 % INJ SOLN
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 00409196607
|
| Hospital Charge Code |
7028
|
|
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
|
|
|
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
7318
|
|
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 |
$26.04
|
| 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
|
|
|
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
7318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
SODIUM CHLORIDE 0.45 % IV SOLP (IN ML/KG/HR)
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
158804
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$36.29
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cigna All Commercial |
$36.25
|
| Rate for Payer: CORVEL All Commercial |
$39.06
|
| Rate for Payer: Coventry All Commercial |
$36.96
|
| Rate for Payer: Encore All Commercial |
$38.66
|
| Rate for Payer: Frontpath All Commercial |
$38.64
|
| Rate for Payer: Humana ChoiceCare |
$36.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
|
|
SODIUM CHLORIDE 0.45 % IV SOLP (IN ML/KG/HR)
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J7799
|
| Hospital Charge Code |
158804
|
|
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 |
$26.04
|
| 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
|
|
|
SODIUM CHLORIDE 0.45% WITH KCL 20 MEQ/L IV SOLP
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
36046
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$45.57 |
| Rate for Payer: Aetna Commercial |
$42.34
|
| Rate for Payer: Cash Price |
$30.38
|
| Rate for Payer: Cigna All Commercial |
$42.29
|
| Rate for Payer: CORVEL All Commercial |
$45.57
|
| Rate for Payer: Coventry All Commercial |
$43.12
|
| Rate for Payer: Encore All Commercial |
$45.10
|
| Rate for Payer: Frontpath All Commercial |
$45.08
|
| Rate for Payer: Humana ChoiceCare |
$42.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.10
|
| Rate for Payer: PHCS All Commercial |
$36.75
|
| Rate for Payer: PHP All Commercial |
$37.16
|
| Rate for Payer: Sagamore Health Network All Products |
$37.83
|
| Rate for Payer: Signature Care EPO |
$40.67
|
| Rate for Payer: Signature Care PPO |
$43.12
|
| Rate for Payer: United Healthcare Commercial |
$38.61
|
|
|
SODIUM CHLORIDE 0.45% WITH KCL 20 MEQ/L IV SOLP
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
36046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.19 |
| Max. Negotiated Rate |
$45.57 |
| Rate for Payer: Aetna Commercial |
$41.36
|
| Rate for Payer: Aetna Medicare |
$15.68
|
| 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 Traditional |
$30.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.25
|
| Rate for Payer: Cash Price |
$30.38
|
| Rate for Payer: Centivo All Commercial |
$26.66
|
| Rate for Payer: Cigna All Commercial |
$42.29
|
| Rate for Payer: CORVEL All Commercial |
$45.57
|
| Rate for Payer: Coventry All Commercial |
$43.12
|
| Rate for Payer: Encore All Commercial |
$45.10
|
| Rate for Payer: Frontpath All Commercial |
$45.08
|
| Rate for Payer: Humana ChoiceCare |
$42.32
|
| Rate for Payer: Humana Medicare |
$15.68
|
| Rate for Payer: Lucent All Commercial |
$26.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.10
|
| Rate for Payer: PHCS All Commercial |
$36.75
|
| Rate for Payer: PHP All Commercial |
$37.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.11
|
| Rate for Payer: Sagamore Health Network All Products |
$37.83
|
| Rate for Payer: Signature Care EPO |
$40.67
|
| Rate for Payer: Signature Care PPO |
$43.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.65
|
| Rate for Payer: United Healthcare Commercial |
$38.61
|
| Rate for Payer: United Healthcare Medicare |
$15.68
|
|
|
SODIUM CHLORIDE 0.65 % NASL SPRA
|
Facility
|
IP
|
$16.80
|
|
|
Service Code
|
NDC 56184012011
|
| Hospital Charge Code |
29676
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$15.62 |
| Rate for Payer: Aetna Commercial |
$14.52
|
| Rate for Payer: Cash Price |
$10.42
|
| Rate for Payer: Cigna All Commercial |
$14.50
|
| Rate for Payer: CORVEL All Commercial |
$15.62
|
| Rate for Payer: Coventry All Commercial |
$14.78
|
| Rate for Payer: Encore All Commercial |
$15.46
|
| Rate for Payer: Frontpath All Commercial |
$15.46
|
| Rate for Payer: Humana ChoiceCare |
$14.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.12
|
| Rate for Payer: PHCS All Commercial |
$12.60
|
| Rate for Payer: PHP All Commercial |
$12.74
|
| Rate for Payer: Sagamore Health Network All Products |
$12.97
|
| Rate for Payer: Signature Care EPO |
$13.94
|
| Rate for Payer: Signature Care PPO |
$14.78
|
| Rate for Payer: United Healthcare Commercial |
$13.24
|
|
|
SODIUM CHLORIDE 0.65 % NASL SPRA
|
Facility
|
OP
|
$7.08
|
|
|
Service Code
|
NDC 00904386575
|
| Hospital Charge Code |
29676
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$6.59 |
| Rate for Payer: Aetna Commercial |
$5.98
|
| Rate for Payer: Aetna Medicare |
$2.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.43
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.49
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Centivo All Commercial |
$3.85
|
| Rate for Payer: Cigna All Commercial |
$6.11
|
| Rate for Payer: CORVEL All Commercial |
$6.59
|
| Rate for Payer: Coventry All Commercial |
$6.23
|
| Rate for Payer: Encore All Commercial |
$6.52
|
| Rate for Payer: Frontpath All Commercial |
$6.52
|
| Rate for Payer: Humana ChoiceCare |
$6.12
|
| Rate for Payer: Humana Medicare |
$2.27
|
| Rate for Payer: Lucent All Commercial |
$3.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.38
|
| Rate for Payer: PHCS All Commercial |
$5.31
|
| Rate for Payer: PHP All Commercial |
$5.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.76
|
| Rate for Payer: Sagamore Health Network All Products |
$5.47
|
| Rate for Payer: Signature Care EPO |
$5.88
|
| Rate for Payer: Signature Care PPO |
$6.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.02
|
| Rate for Payer: United Healthcare Commercial |
$5.58
|
| Rate for Payer: United Healthcare Medicare |
$2.27
|
|
|
SODIUM CHLORIDE 0.65 % NASL SPRA
|
Facility
|
IP
|
$7.08
|
|
|
Service Code
|
NDC 00904386575
|
| Hospital Charge Code |
29676
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$6.59 |
| Rate for Payer: Aetna Commercial |
$6.12
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cigna All Commercial |
$6.11
|
| Rate for Payer: CORVEL All Commercial |
$6.59
|
| Rate for Payer: Coventry All Commercial |
$6.23
|
| Rate for Payer: Encore All Commercial |
$6.52
|
| Rate for Payer: Frontpath All Commercial |
$6.52
|
| Rate for Payer: Humana ChoiceCare |
$6.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.38
|
| Rate for Payer: PHCS All Commercial |
$5.31
|
| Rate for Payer: PHP All Commercial |
$5.37
|
| Rate for Payer: Sagamore Health Network All Products |
$5.47
|
| Rate for Payer: Signature Care EPO |
$5.88
|
| Rate for Payer: Signature Care PPO |
$6.23
|
| Rate for Payer: United Healthcare Commercial |
$5.58
|
|
