|
SODIUM CHLORIDE 0.65 % NASL SPRA
|
Facility
|
OP
|
$16.80
|
|
|
Service Code
|
NDC 56184012011
|
| Hospital Charge Code |
29676
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.21 |
| Max. Negotiated Rate |
$15.62 |
| Rate for Payer: Aetna Commercial |
$14.18
|
| Rate for Payer: Aetna Medicare |
$5.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$9.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.91
|
| Rate for Payer: Cash Price |
$10.42
|
| Rate for Payer: Centivo All Commercial |
$9.14
|
| 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: Humana Medicare |
$5.38
|
| Rate for Payer: Lucent All Commercial |
$9.14
|
| 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: Plain Church Group Ministry All Commercial |
$6.55
|
| 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: Three Rivers Preferred All Commercial |
$14.28
|
| Rate for Payer: United Healthcare Commercial |
$13.24
|
| Rate for Payer: United Healthcare Medicare |
$5.38
|
|
|
SODIUM CHLORIDE 0.9 % (FLUSH) INJ SYRG
|
Facility
|
OP
|
$3.99
|
|
|
Service Code
|
NDC 63807010010
|
| Hospital Charge Code |
7319
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.49
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.40
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Centivo All Commercial |
$2.17
|
| Rate for Payer: Cigna All Commercial |
$3.44
|
| Rate for Payer: CORVEL All Commercial |
$3.71
|
| Rate for Payer: Coventry All Commercial |
$3.51
|
| Rate for Payer: Encore All Commercial |
$3.67
|
| Rate for Payer: Frontpath All Commercial |
$3.67
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.59
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$2.99
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.08
|
| Rate for Payer: Signature Care EPO |
$3.31
|
| Rate for Payer: Signature Care PPO |
$3.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.39
|
| Rate for Payer: United Healthcare Commercial |
$3.14
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
SODIUM CHLORIDE 0.9 % (FLUSH) INJ SYRG
|
Facility
|
IP
|
$3.99
|
|
|
Service Code
|
NDC 63807010010
|
| Hospital Charge Code |
7319
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.45
|
| Rate for Payer: Cash Price |
$2.47
|
| Rate for Payer: Cigna All Commercial |
$3.44
|
| Rate for Payer: CORVEL All Commercial |
$3.71
|
| Rate for Payer: Coventry All Commercial |
$3.51
|
| Rate for Payer: Encore All Commercial |
$3.67
|
| Rate for Payer: Frontpath All Commercial |
$3.67
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.59
|
| Rate for Payer: PHCS All Commercial |
$2.99
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.08
|
| Rate for Payer: Signature Care EPO |
$3.31
|
| Rate for Payer: Signature Care PPO |
$3.51
|
| Rate for Payer: United Healthcare Commercial |
$3.14
|
|
|
SODIUM CHLORIDE 0.9 % (FLUSH) INJ SYRG (POSIFLUSH CAMERON)
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 08290306553
|
| Hospital Charge Code |
14017319
|
|
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 0.9% FOR FLUSHING POST ALTEPLASE
|
Facility
|
OP
|
$29.75
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
800323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$27.67 |
| Rate for Payer: Aetna Commercial |
$25.11
|
| Rate for Payer: Aetna Medicare |
$9.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$17.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.47
|
| Rate for Payer: Cash Price |
$18.45
|
| Rate for Payer: Centivo All Commercial |
$16.18
|
| Rate for Payer: Cigna All Commercial |
$25.67
|
| Rate for Payer: CORVEL All Commercial |
$27.67
|
| Rate for Payer: Coventry All Commercial |
$26.18
|
| Rate for Payer: Encore All Commercial |
$27.38
|
| Rate for Payer: Frontpath All Commercial |
$27.37
|
| Rate for Payer: Humana ChoiceCare |
$25.70
|
| Rate for Payer: Humana Medicare |
$9.52
|
| Rate for Payer: Lucent All Commercial |
$16.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.77
|
| Rate for Payer: PHCS All Commercial |
$22.31
|
| Rate for Payer: PHP All Commercial |
$22.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.60
|
| Rate for Payer: Sagamore Health Network All Products |
$22.97
|
| Rate for Payer: Signature Care EPO |
$24.69
|
| Rate for Payer: Signature Care PPO |
$26.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25.29
|
| Rate for Payer: United Healthcare Commercial |
$23.44
|
| Rate for Payer: United Healthcare Medicare |
$9.52
|
|
|
SODIUM CHLORIDE 0.9% FOR FLUSHING POST ALTEPLASE
|
Facility
|
IP
|
$29.75
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
800323
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$22.31 |
| Max. Negotiated Rate |
$27.67 |
| Rate for Payer: Aetna Commercial |
$25.70
|
| Rate for Payer: Cash Price |
$18.45
|
| Rate for Payer: Cigna All Commercial |
$25.67
|
| Rate for Payer: CORVEL All Commercial |
$27.67
|
| Rate for Payer: Coventry All Commercial |
$26.18
|
| Rate for Payer: Encore All Commercial |
$27.38
|
| Rate for Payer: Frontpath All Commercial |
$27.37
|
| Rate for Payer: Humana ChoiceCare |
$25.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.77
|
| Rate for Payer: PHCS All Commercial |
$22.31
|
| Rate for Payer: PHP All Commercial |
$22.56
|
| Rate for Payer: Sagamore Health Network All Products |
$22.97
|
| Rate for Payer: Signature Care EPO |
$24.69
|
| Rate for Payer: Signature Care PPO |
$26.18
|
| Rate for Payer: United Healthcare Commercial |
$23.44
|
|
|
SODIUM CHLORIDE 0.9% FOR LINE CARE - 250 ML BAG (CAMERON)
|
Facility
|
OP
|
$29.75
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
14010408027838
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$27.67 |
| Rate for Payer: Aetna Commercial |
$25.11
|
| Rate for Payer: Aetna Medicare |
$9.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$17.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.47
|
| Rate for Payer: Cash Price |
$18.45
|
| Rate for Payer: Centivo All Commercial |
$16.18
|
| Rate for Payer: Cigna All Commercial |
$25.67
|
| Rate for Payer: CORVEL All Commercial |
$27.67
|
| Rate for Payer: Coventry All Commercial |
$26.18
|
| Rate for Payer: Encore All Commercial |
$27.38
|
| Rate for Payer: Frontpath All Commercial |
$27.37
|
| Rate for Payer: Humana ChoiceCare |
$25.70
|
| Rate for Payer: Humana Medicare |
$9.52
|
| Rate for Payer: Lucent All Commercial |
$16.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.77
|
| Rate for Payer: PHCS All Commercial |
$22.31
|
| Rate for Payer: PHP All Commercial |
$22.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.60
|
| Rate for Payer: Sagamore Health Network All Products |
$22.97
|
| Rate for Payer: Signature Care EPO |
$24.69
|
| Rate for Payer: Signature Care PPO |
$26.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25.29
|
| Rate for Payer: United Healthcare Commercial |
$23.44
|
| Rate for Payer: United Healthcare Medicare |
$9.52
|
|
|
SODIUM CHLORIDE 0.9% FOR LINE CARE - 250 ML BAG (CAMERON)
|
Facility
|
IP
|
$29.75
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
14010408027838
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$22.31 |
| Max. Negotiated Rate |
$27.67 |
| Rate for Payer: Aetna Commercial |
$25.70
|
| Rate for Payer: Cash Price |
$18.45
|
| Rate for Payer: Cigna All Commercial |
$25.67
|
| Rate for Payer: CORVEL All Commercial |
$27.67
|
| Rate for Payer: Coventry All Commercial |
$26.18
|
| Rate for Payer: Encore All Commercial |
$27.38
|
| Rate for Payer: Frontpath All Commercial |
$27.37
|
| Rate for Payer: Humana ChoiceCare |
$25.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.77
|
| Rate for Payer: PHCS All Commercial |
$22.31
|
| Rate for Payer: PHP All Commercial |
$22.56
|
| Rate for Payer: Sagamore Health Network All Products |
$22.97
|
| Rate for Payer: Signature Care EPO |
$24.69
|
| Rate for Payer: Signature Care PPO |
$26.18
|
| Rate for Payer: United Healthcare Commercial |
$23.44
|
|
|
SODIUM CHLORIDE 0.9 % INHL NEBU
|
Facility
|
OP
|
$1.41
|
|
|
Service Code
|
NDC 00487930133
|
| Hospital Charge Code |
7325
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$1.19
|
| Rate for Payer: Aetna Medicare |
$0.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.50
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Centivo All Commercial |
$0.77
|
| Rate for Payer: Cigna All Commercial |
$1.21
|
| Rate for Payer: CORVEL All Commercial |
$1.31
|
| Rate for Payer: Coventry All Commercial |
$1.24
|
| Rate for Payer: Encore All Commercial |
$1.30
|
| Rate for Payer: Frontpath All Commercial |
$1.29
|
| Rate for Payer: Humana ChoiceCare |
$1.22
|
| Rate for Payer: Humana Medicare |
$0.45
|
| Rate for Payer: Lucent All Commercial |
$0.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.27
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$1.06
|
| Rate for Payer: PHP All Commercial |
$1.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.55
|
| Rate for Payer: Sagamore Health Network All Products |
$1.09
|
| Rate for Payer: Signature Care EPO |
$1.17
|
| Rate for Payer: Signature Care PPO |
$1.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$1.11
|
| Rate for Payer: United Healthcare Medicare |
$0.45
|
|
|
SODIUM CHLORIDE 0.9 % INHL NEBU
|
Facility
|
IP
|
$1.41
|
|
|
Service Code
|
NDC 00487930133
|
| Hospital Charge Code |
7325
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Aetna Commercial |
$1.22
|
| Rate for Payer: Cash Price |
$0.87
|
| Rate for Payer: Cigna All Commercial |
$1.21
|
| Rate for Payer: CORVEL All Commercial |
$1.31
|
| Rate for Payer: Coventry All Commercial |
$1.24
|
| Rate for Payer: Encore All Commercial |
$1.30
|
| Rate for Payer: Frontpath All Commercial |
$1.29
|
| Rate for Payer: Humana ChoiceCare |
$1.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.27
|
| Rate for Payer: PHCS All Commercial |
$1.06
|
| Rate for Payer: PHP All Commercial |
$1.07
|
| Rate for Payer: Sagamore Health Network All Products |
$1.09
|
| Rate for Payer: Signature Care EPO |
$1.17
|
| Rate for Payer: Signature Care PPO |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.11
|
|
|
SODIUM CHLORIDE 0.9 % INJ SOLN
|
Facility
|
OP
|
$5.60
|
|
|
Service Code
|
NDC 00409488810
|
| Hospital Charge Code |
41463
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$4.73
|
| Rate for Payer: Aetna Medicare |
$1.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.97
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Centivo All Commercial |
$3.05
|
| Rate for Payer: Cigna All Commercial |
$4.83
|
| Rate for Payer: CORVEL All Commercial |
$5.21
|
| Rate for Payer: Coventry All Commercial |
$4.93
|
| Rate for Payer: Encore All Commercial |
$5.15
|
| Rate for Payer: Frontpath All Commercial |
$5.15
|
| Rate for Payer: Humana ChoiceCare |
$4.84
|
| Rate for Payer: Humana Medicare |
$1.79
|
| Rate for Payer: Lucent All Commercial |
$3.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.04
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$4.20
|
| Rate for Payer: PHP All Commercial |
$4.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.18
|
| Rate for Payer: Sagamore Health Network All Products |
$4.32
|
| Rate for Payer: Signature Care EPO |
$4.65
|
| Rate for Payer: Signature Care PPO |
$4.93
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.76
|
| Rate for Payer: United Healthcare Commercial |
$4.41
|
| Rate for Payer: United Healthcare Medicare |
$1.79
|
|
|
SODIUM CHLORIDE 0.9 % INJ SOLN
|
Facility
|
IP
|
$6.58
|
|
|
Service Code
|
NDC 63323018610
|
| Hospital Charge Code |
41463
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.93 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Aetna Commercial |
$5.69
|
| Rate for Payer: Cash Price |
$4.08
|
| Rate for Payer: Cigna All Commercial |
$5.68
|
| Rate for Payer: CORVEL All Commercial |
$6.12
|
| Rate for Payer: Coventry All Commercial |
$5.79
|
| Rate for Payer: Encore All Commercial |
$6.06
|
| Rate for Payer: Frontpath All Commercial |
$6.05
|
| Rate for Payer: Humana ChoiceCare |
$5.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.92
|
| Rate for Payer: PHCS All Commercial |
$4.93
|
| Rate for Payer: PHP All Commercial |
$4.99
|
| Rate for Payer: Sagamore Health Network All Products |
$5.08
|
| Rate for Payer: Signature Care EPO |
$5.46
|
| Rate for Payer: Signature Care PPO |
$5.79
|
| Rate for Payer: United Healthcare Commercial |
$5.19
|
|
|
SODIUM CHLORIDE 0.9 % INJ SOLN
|
Facility
|
OP
|
$6.58
|
|
|
Service Code
|
NDC 63323018610
|
| Hospital Charge Code |
41463
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$5.55
|
| Rate for Payer: Aetna Medicare |
$2.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.11
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.32
|
| Rate for Payer: Cash Price |
$4.08
|
| Rate for Payer: Cash Price |
$4.08
|
| Rate for Payer: Centivo All Commercial |
$3.58
|
| Rate for Payer: Cigna All Commercial |
$5.68
|
| Rate for Payer: CORVEL All Commercial |
$6.12
|
| Rate for Payer: Coventry All Commercial |
$5.79
|
| Rate for Payer: Encore All Commercial |
$6.06
|
| Rate for Payer: Frontpath All Commercial |
$6.05
|
| Rate for Payer: Humana ChoiceCare |
$5.68
|
| Rate for Payer: Humana Medicare |
$2.11
|
| Rate for Payer: Lucent All Commercial |
$3.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.92
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$4.93
|
| Rate for Payer: PHP All Commercial |
$4.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.57
|
| Rate for Payer: Sagamore Health Network All Products |
$5.08
|
| Rate for Payer: Signature Care EPO |
$5.46
|
| Rate for Payer: Signature Care PPO |
$5.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.59
|
| Rate for Payer: United Healthcare Commercial |
$5.19
|
| Rate for Payer: United Healthcare Medicare |
$2.11
|
|
|
SODIUM CHLORIDE 0.9 % INJ SOLN
|
Facility
|
IP
|
$5.60
|
|
|
Service Code
|
NDC 00409488810
|
| Hospital Charge Code |
41463
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$5.21 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cigna All Commercial |
$4.83
|
| Rate for Payer: CORVEL All Commercial |
$5.21
|
| Rate for Payer: Coventry All Commercial |
$4.93
|
| Rate for Payer: Encore All Commercial |
$5.15
|
| Rate for Payer: Frontpath All Commercial |
$5.15
|
| Rate for Payer: Humana ChoiceCare |
$4.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.04
|
| Rate for Payer: PHCS All Commercial |
$4.20
|
| Rate for Payer: PHP All Commercial |
$4.25
|
| Rate for Payer: Sagamore Health Network All Products |
$4.32
|
| Rate for Payer: Signature Care EPO |
$4.65
|
| Rate for Payer: Signature Care PPO |
$4.93
|
| Rate for Payer: United Healthcare Commercial |
$4.41
|
|
|
SODIUM CHLORIDE 0.9% (IN ML/KG)
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
601103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.85 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$29.54
|
| Rate for Payer: Aetna Medicare |
$11.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$20.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.88
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.32
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Centivo All Commercial |
$19.04
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Humana Medicare |
$11.20
|
| Rate for Payer: Lucent All Commercial |
$19.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.75
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
| Rate for Payer: United Healthcare Medicare |
$11.20
|
|
|
SODIUM CHLORIDE 0.9% (IN ML/KG)
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
601103
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$30.24
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Cigna All Commercial |
$30.20
|
| Rate for Payer: CORVEL All Commercial |
$32.55
|
| Rate for Payer: Coventry All Commercial |
$30.80
|
| Rate for Payer: Encore All Commercial |
$32.22
|
| Rate for Payer: Frontpath All Commercial |
$32.20
|
| Rate for Payer: Humana ChoiceCare |
$30.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.50
|
| Rate for Payer: PHCS All Commercial |
$26.25
|
| Rate for Payer: PHP All Commercial |
$26.54
|
| Rate for Payer: Sagamore Health Network All Products |
$27.02
|
| Rate for Payer: Signature Care EPO |
$29.05
|
| Rate for Payer: Signature Care PPO |
$30.80
|
| Rate for Payer: United Healthcare Commercial |
$27.58
|
|
|
SODIUM CHLORIDE 0.9% IRRIGATION (BOLUS)
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
NDC 00338004804
|
| Hospital Charge Code |
408011403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| 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 Medicaid |
$9.56
|
| 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 Hoosier Healthwise/HIP |
$9.56
|
| 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: 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: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| 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 0.9% IRRIGATION (BOLUS)
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
NDC 004097972
|
| Hospital Charge Code |
408011403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$53.17
|
| Rate for Payer: Aetna Medicare |
$20.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$36.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.38
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.18
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Centivo All Commercial |
$34.27
|
| Rate for Payer: Cigna All Commercial |
$54.37
|
| Rate for Payer: CORVEL All Commercial |
$58.59
|
| Rate for Payer: Coventry All Commercial |
$55.44
|
| Rate for Payer: Encore All Commercial |
$57.99
|
| Rate for Payer: Frontpath All Commercial |
$57.96
|
| Rate for Payer: Humana ChoiceCare |
$54.41
|
| Rate for Payer: Humana Medicare |
$20.16
|
| Rate for Payer: Lucent All Commercial |
$34.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.70
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$47.25
|
| Rate for Payer: PHP All Commercial |
$47.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.57
|
| Rate for Payer: Sagamore Health Network All Products |
$48.64
|
| Rate for Payer: Signature Care EPO |
$52.29
|
| Rate for Payer: Signature Care PPO |
$55.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$53.55
|
| Rate for Payer: United Healthcare Commercial |
$49.64
|
| Rate for Payer: United Healthcare Medicare |
$20.16
|
|
|
SODIUM CHLORIDE 0.9% IRRIGATION (BOLUS)
|
Facility
|
IP
|
$43.75
|
|
|
Service Code
|
NDC 00338004802
|
| Hospital Charge Code |
408011403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.81 |
| Max. Negotiated Rate |
$40.69 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Cash Price |
$27.13
|
| Rate for Payer: Cigna All Commercial |
$37.76
|
| Rate for Payer: CORVEL All Commercial |
$40.69
|
| Rate for Payer: Coventry All Commercial |
$38.50
|
| Rate for Payer: Encore All Commercial |
$40.27
|
| Rate for Payer: Frontpath All Commercial |
$40.25
|
| Rate for Payer: Humana ChoiceCare |
$37.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$39.38
|
| Rate for Payer: PHCS All Commercial |
$32.81
|
| Rate for Payer: PHP All Commercial |
$33.18
|
| Rate for Payer: Sagamore Health Network All Products |
$33.77
|
| Rate for Payer: Signature Care EPO |
$36.31
|
| Rate for Payer: Signature Care PPO |
$38.50
|
| Rate for Payer: United Healthcare Commercial |
$34.48
|
|
|
SODIUM CHLORIDE 0.9% IRRIGATION (BOLUS)
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
NDC 004097972
|
| Hospital Charge Code |
408011403
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
SODIUM CHLORIDE 0.9% IRRIGATION (BOLUS)
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 00338004804
|
| Hospital Charge Code |
408011403
|
|
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 0.9% IRRIGATION (BOLUS)
|
Facility
|
OP
|
$43.75
|
|
|
Service Code
|
NDC 00338004802
|
| Hospital Charge Code |
408011403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$40.69 |
| Rate for Payer: Aetna Commercial |
$36.92
|
| Rate for Payer: Aetna Medicare |
$14.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$25.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$27.35
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$16.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.40
|
| Rate for Payer: Cash Price |
$27.13
|
| Rate for Payer: Cash Price |
$27.13
|
| Rate for Payer: Centivo All Commercial |
$23.80
|
| Rate for Payer: Cigna All Commercial |
$37.76
|
| Rate for Payer: CORVEL All Commercial |
$40.69
|
| Rate for Payer: Coventry All Commercial |
$38.50
|
| Rate for Payer: Encore All Commercial |
$40.27
|
| Rate for Payer: Frontpath All Commercial |
$40.25
|
| Rate for Payer: Humana ChoiceCare |
$37.79
|
| Rate for Payer: Humana Medicare |
$14.00
|
| Rate for Payer: Lucent All Commercial |
$23.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$39.38
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$32.81
|
| Rate for Payer: PHP All Commercial |
$33.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$17.06
|
| Rate for Payer: Sagamore Health Network All Products |
$33.77
|
| Rate for Payer: Signature Care EPO |
$36.31
|
| Rate for Payer: Signature Care PPO |
$38.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$37.19
|
| Rate for Payer: United Healthcare Commercial |
$34.48
|
| Rate for Payer: United Healthcare Medicare |
$14.00
|
|
|
SODIUM CHLORIDE 0.9 % IR SOLN
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
NDC 00990797208
|
| Hospital Charge Code |
11403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$97.65 |
| Rate for Payer: Aetna Commercial |
$88.62
|
| Rate for Payer: Aetna Medicare |
$33.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$32.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$60.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$65.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$38.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.96
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Centivo All Commercial |
$57.12
|
| Rate for Payer: Cigna All Commercial |
$90.61
|
| Rate for Payer: CORVEL All Commercial |
$97.65
|
| Rate for Payer: Coventry All Commercial |
$92.40
|
| Rate for Payer: Encore All Commercial |
$96.65
|
| Rate for Payer: Frontpath All Commercial |
$96.60
|
| Rate for Payer: Humana ChoiceCare |
$90.69
|
| Rate for Payer: Humana Medicare |
$33.60
|
| Rate for Payer: Lucent All Commercial |
$57.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$94.50
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$78.75
|
| Rate for Payer: PHP All Commercial |
$79.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.95
|
| Rate for Payer: Sagamore Health Network All Products |
$81.06
|
| Rate for Payer: Signature Care EPO |
$87.15
|
| Rate for Payer: Signature Care PPO |
$92.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$82.74
|
| Rate for Payer: United Healthcare Medicare |
$33.60
|
|
|
SODIUM CHLORIDE 0.9 % IR SOLN
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
NDC 00338004727
|
| Hospital Charge Code |
11403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$117.18 |
| Rate for Payer: Aetna Commercial |
$106.34
|
| Rate for Payer: Aetna Medicare |
$40.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$39.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$72.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$78.76
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$46.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$44.35
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Centivo All Commercial |
$68.54
|
| Rate for Payer: Cigna All Commercial |
$108.74
|
| Rate for Payer: CORVEL All Commercial |
$117.18
|
| Rate for Payer: Coventry All Commercial |
$110.88
|
| Rate for Payer: Encore All Commercial |
$115.98
|
| Rate for Payer: Frontpath All Commercial |
$115.92
|
| Rate for Payer: Humana ChoiceCare |
$108.83
|
| Rate for Payer: Humana Medicare |
$40.32
|
| Rate for Payer: Lucent All Commercial |
$68.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$113.40
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$94.50
|
| Rate for Payer: PHP All Commercial |
$95.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$49.14
|
| Rate for Payer: Sagamore Health Network All Products |
$97.27
|
| Rate for Payer: Signature Care EPO |
$104.58
|
| Rate for Payer: Signature Care PPO |
$110.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$107.10
|
| Rate for Payer: United Healthcare Commercial |
$99.29
|
| Rate for Payer: United Healthcare Medicare |
$40.32
|
|
|
SODIUM CHLORIDE 0.9 % IR SOLN
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
NDC 00338004727
|
| Hospital Charge Code |
11403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$117.18 |
| Rate for Payer: Aetna Commercial |
$108.86
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cigna All Commercial |
$108.74
|
| Rate for Payer: CORVEL All Commercial |
$117.18
|
| Rate for Payer: Coventry All Commercial |
$110.88
|
| Rate for Payer: Encore All Commercial |
$115.98
|
| Rate for Payer: Frontpath All Commercial |
$115.92
|
| Rate for Payer: Humana ChoiceCare |
$108.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$113.40
|
| Rate for Payer: PHCS All Commercial |
$94.50
|
| Rate for Payer: PHP All Commercial |
$95.56
|
| Rate for Payer: Sagamore Health Network All Products |
$97.27
|
| Rate for Payer: Signature Care EPO |
$104.58
|
| Rate for Payer: Signature Care PPO |
$110.88
|
| Rate for Payer: United Healthcare Commercial |
$99.29
|
|
