|
SODIUM CHLORIDE 3 % HYPERTONIC 3 % IV SOLP
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
HCPCS J7131
|
| Hospital Charge Code |
7321
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$23.25 |
| Rate for Payer: Aetna Commercial |
$21.60
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cigna All Commercial |
$21.57
|
| Rate for Payer: CORVEL All Commercial |
$23.25
|
| Rate for Payer: Coventry All Commercial |
$22.00
|
| Rate for Payer: Encore All Commercial |
$23.01
|
| Rate for Payer: Frontpath All Commercial |
$23.00
|
| Rate for Payer: Humana ChoiceCare |
$21.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.50
|
| Rate for Payer: PHCS All Commercial |
$18.75
|
| Rate for Payer: PHP All Commercial |
$18.96
|
| Rate for Payer: Sagamore Health Network All Products |
$19.30
|
| Rate for Payer: Signature Care EPO |
$20.75
|
| Rate for Payer: Signature Care PPO |
$22.00
|
| Rate for Payer: United Healthcare Commercial |
$19.70
|
|
|
SODIUM CHLORIDE 3 % HYPERTONIC 3 % IV SOLP
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS J7131
|
| Hospital Charge Code |
7321
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$23.25 |
| Rate for Payer: Aetna Commercial |
$21.10
|
| 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 |
$14.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.63
|
| 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 |
$15.50
|
| Rate for Payer: Centivo All Commercial |
$13.60
|
| Rate for Payer: Cigna All Commercial |
$21.57
|
| Rate for Payer: CORVEL All Commercial |
$23.25
|
| Rate for Payer: Coventry All Commercial |
$22.00
|
| Rate for Payer: Encore All Commercial |
$23.01
|
| Rate for Payer: Frontpath All Commercial |
$23.00
|
| Rate for Payer: Humana ChoiceCare |
$21.59
|
| Rate for Payer: Humana Medicare |
$8.00
|
| Rate for Payer: Lucent All Commercial |
$13.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.50
|
| Rate for Payer: PHCS All Commercial |
$18.75
|
| Rate for Payer: PHP All Commercial |
$18.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.75
|
| Rate for Payer: Sagamore Health Network All Products |
$19.30
|
| Rate for Payer: Signature Care EPO |
$20.75
|
| Rate for Payer: Signature Care PPO |
$22.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.25
|
| Rate for Payer: United Healthcare Commercial |
$19.70
|
| Rate for Payer: United Healthcare Medicare |
$8.00
|
|
|
SODIUM CHLORIDE 3 % HYPERTONIC 3 % IV SOLP - CAMERON
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
HCPCS J7131
|
| Hospital Charge Code |
1401000007321
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$23.25 |
| Rate for Payer: Aetna Commercial |
$21.60
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cigna All Commercial |
$21.57
|
| Rate for Payer: CORVEL All Commercial |
$23.25
|
| Rate for Payer: Coventry All Commercial |
$22.00
|
| Rate for Payer: Encore All Commercial |
$23.01
|
| Rate for Payer: Frontpath All Commercial |
$23.00
|
| Rate for Payer: Humana ChoiceCare |
$21.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.50
|
| Rate for Payer: PHCS All Commercial |
$18.75
|
| Rate for Payer: PHP All Commercial |
$18.96
|
| Rate for Payer: Sagamore Health Network All Products |
$19.30
|
| Rate for Payer: Signature Care EPO |
$20.75
|
| Rate for Payer: Signature Care PPO |
$22.00
|
| Rate for Payer: United Healthcare Commercial |
$19.70
|
|
|
SODIUM CHLORIDE 3 % HYPERTONIC 3 % IV SOLP - CAMERON
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS J7131
|
| Hospital Charge Code |
1401000007321
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$23.25 |
| Rate for Payer: Aetna Commercial |
$21.10
|
| 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 |
$14.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.63
|
| 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 |
$15.50
|
| Rate for Payer: Centivo All Commercial |
$13.60
|
| Rate for Payer: Cigna All Commercial |
$21.57
|
| Rate for Payer: CORVEL All Commercial |
$23.25
|
| Rate for Payer: Coventry All Commercial |
$22.00
|
| Rate for Payer: Encore All Commercial |
$23.01
|
| Rate for Payer: Frontpath All Commercial |
$23.00
|
| Rate for Payer: Humana ChoiceCare |
$21.59
|
| Rate for Payer: Humana Medicare |
$8.00
|
| Rate for Payer: Lucent All Commercial |
$13.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.50
|
| Rate for Payer: PHCS All Commercial |
$18.75
|
| Rate for Payer: PHP All Commercial |
$18.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.75
|
| Rate for Payer: Sagamore Health Network All Products |
$19.30
|
| Rate for Payer: Signature Care EPO |
$20.75
|
| Rate for Payer: Signature Care PPO |
$22.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.25
|
| Rate for Payer: United Healthcare Commercial |
$19.70
|
| Rate for Payer: United Healthcare Medicare |
$8.00
|
|
|
SODIUM CHLORIDE 3 % INHL NEBU
|
Facility
|
IP
|
$3.92
|
|
|
Service Code
|
NDC 76204002260
|
| Hospital Charge Code |
7327
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna All Commercial |
$3.38
|
| Rate for Payer: CORVEL All Commercial |
$3.65
|
| Rate for Payer: Coventry All Commercial |
$3.45
|
| Rate for Payer: Encore All Commercial |
$3.61
|
| Rate for Payer: Frontpath All Commercial |
$3.61
|
| Rate for Payer: Humana ChoiceCare |
$3.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.53
|
| Rate for Payer: PHCS All Commercial |
$2.94
|
| Rate for Payer: PHP All Commercial |
$2.97
|
| Rate for Payer: Sagamore Health Network All Products |
$3.03
|
| Rate for Payer: Signature Care EPO |
$3.25
|
| Rate for Payer: Signature Care PPO |
$3.45
|
| Rate for Payer: United Healthcare Commercial |
$3.09
|
|
|
SODIUM CHLORIDE 3 % INHL NEBU
|
Facility
|
OP
|
$3.92
|
|
|
Service Code
|
NDC 76204002260
|
| Hospital Charge Code |
7327
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$3.31
|
| Rate for Payer: Aetna Medicare |
$1.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.45
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.38
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Centivo All Commercial |
$2.13
|
| Rate for Payer: Cigna All Commercial |
$3.38
|
| Rate for Payer: CORVEL All Commercial |
$3.65
|
| Rate for Payer: Coventry All Commercial |
$3.45
|
| Rate for Payer: Encore All Commercial |
$3.61
|
| Rate for Payer: Frontpath All Commercial |
$3.61
|
| Rate for Payer: Humana ChoiceCare |
$3.39
|
| Rate for Payer: Humana Medicare |
$1.25
|
| Rate for Payer: Lucent All Commercial |
$2.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.53
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$2.94
|
| Rate for Payer: PHP All Commercial |
$2.97
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.53
|
| Rate for Payer: Sagamore Health Network All Products |
$3.03
|
| Rate for Payer: Signature Care EPO |
$3.25
|
| Rate for Payer: Signature Care PPO |
$3.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.33
|
| Rate for Payer: United Healthcare Commercial |
$3.09
|
| Rate for Payer: United Healthcare Medicare |
$1.25
|
|
|
SODIUM CHLORIDE 4 MEQ/ML IV SOLN
|
Facility
|
IP
|
$56.70
|
|
|
Service Code
|
NDC 63323009330
|
| Hospital Charge Code |
7322
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$42.52 |
| Max. Negotiated Rate |
$52.73 |
| Rate for Payer: Aetna Commercial |
$48.99
|
| Rate for Payer: Cash Price |
$35.15
|
| Rate for Payer: Cigna All Commercial |
$48.93
|
| Rate for Payer: CORVEL All Commercial |
$52.73
|
| Rate for Payer: Coventry All Commercial |
$49.90
|
| Rate for Payer: Encore All Commercial |
$52.19
|
| Rate for Payer: Frontpath All Commercial |
$52.16
|
| Rate for Payer: Humana ChoiceCare |
$48.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.03
|
| Rate for Payer: PHCS All Commercial |
$42.52
|
| Rate for Payer: PHP All Commercial |
$43.00
|
| Rate for Payer: Sagamore Health Network All Products |
$43.77
|
| Rate for Payer: Signature Care EPO |
$47.06
|
| Rate for Payer: Signature Care PPO |
$49.90
|
| Rate for Payer: United Healthcare Commercial |
$44.68
|
|
|
SODIUM CHLORIDE 4 MEQ/ML IV SOLN
|
Facility
|
OP
|
$56.70
|
|
|
Service Code
|
NDC 63323009330
|
| Hospital Charge Code |
7322
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$17.58 |
| Max. Negotiated Rate |
$52.73 |
| Rate for Payer: Aetna Commercial |
$47.85
|
| Rate for Payer: Aetna Medicare |
$18.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$32.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$35.44
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$19.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$20.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$19.96
|
| Rate for Payer: Cash Price |
$35.15
|
| Rate for Payer: Cash Price |
$35.15
|
| Rate for Payer: Centivo All Commercial |
$30.84
|
| Rate for Payer: Cigna All Commercial |
$48.93
|
| Rate for Payer: CORVEL All Commercial |
$52.73
|
| Rate for Payer: Coventry All Commercial |
$49.90
|
| Rate for Payer: Encore All Commercial |
$52.19
|
| Rate for Payer: Frontpath All Commercial |
$52.16
|
| Rate for Payer: Humana ChoiceCare |
$48.97
|
| Rate for Payer: Humana Medicare |
$18.14
|
| Rate for Payer: Lucent All Commercial |
$30.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.03
|
| Rate for Payer: Managed Health Services Medicaid |
$19.12
|
| Rate for Payer: MDWise Medicaid |
$19.12
|
| Rate for Payer: PHCS All Commercial |
$42.52
|
| Rate for Payer: PHP All Commercial |
$43.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.11
|
| Rate for Payer: Sagamore Health Network All Products |
$43.77
|
| Rate for Payer: Signature Care EPO |
$47.06
|
| Rate for Payer: Signature Care PPO |
$49.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$48.20
|
| Rate for Payer: United Healthcare Commercial |
$44.68
|
| Rate for Payer: United Healthcare Medicare |
$18.14
|
|
|
SODIUM CITRATE-CITRIC ACID 500-334 MG/5 ML ORAL SOLN
|
Facility
|
IP
|
$35.49
|
|
|
Service Code
|
NDC 00121119000
|
| Hospital Charge Code |
15706
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.62 |
| Max. Negotiated Rate |
$33.01 |
| Rate for Payer: Aetna Commercial |
$30.66
|
| Rate for Payer: Cash Price |
$22.00
|
| Rate for Payer: Cigna All Commercial |
$30.63
|
| Rate for Payer: CORVEL All Commercial |
$33.01
|
| Rate for Payer: Coventry All Commercial |
$31.23
|
| Rate for Payer: Encore All Commercial |
$32.67
|
| Rate for Payer: Frontpath All Commercial |
$32.65
|
| Rate for Payer: Humana ChoiceCare |
$30.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.94
|
| Rate for Payer: PHCS All Commercial |
$26.62
|
| Rate for Payer: PHP All Commercial |
$26.92
|
| Rate for Payer: Sagamore Health Network All Products |
$27.40
|
| Rate for Payer: Signature Care EPO |
$29.46
|
| Rate for Payer: Signature Care PPO |
$31.23
|
| Rate for Payer: United Healthcare Commercial |
$27.97
|
|
|
SODIUM CITRATE-CITRIC ACID 500-334 MG/5 ML ORAL SOLN
|
Facility
|
OP
|
$35.49
|
|
|
Service Code
|
NDC 00121119000
|
| Hospital Charge Code |
15706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$33.01 |
| Rate for Payer: Aetna Commercial |
$29.95
|
| Rate for Payer: Aetna Medicare |
$11.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$20.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.49
|
| Rate for Payer: Cash Price |
$22.00
|
| Rate for Payer: Centivo All Commercial |
$19.31
|
| Rate for Payer: Cigna All Commercial |
$30.63
|
| Rate for Payer: CORVEL All Commercial |
$33.01
|
| Rate for Payer: Coventry All Commercial |
$31.23
|
| Rate for Payer: Encore All Commercial |
$32.67
|
| Rate for Payer: Frontpath All Commercial |
$32.65
|
| Rate for Payer: Humana ChoiceCare |
$30.65
|
| Rate for Payer: Humana Medicare |
$11.36
|
| Rate for Payer: Lucent All Commercial |
$19.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.94
|
| Rate for Payer: PHCS All Commercial |
$26.62
|
| Rate for Payer: PHP All Commercial |
$26.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.84
|
| Rate for Payer: Sagamore Health Network All Products |
$27.40
|
| Rate for Payer: Signature Care EPO |
$29.46
|
| Rate for Payer: Signature Care PPO |
$31.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$30.17
|
| Rate for Payer: United Healthcare Commercial |
$27.97
|
| Rate for Payer: United Healthcare Medicare |
$11.36
|
|
|
SODIUM FLUORIDE F-18 10-200 MCI/ML 370-7,400MBQ/ML IV SOLN
|
Facility
|
OP
|
$15,800.40
|
|
|
Service Code
|
NDC 65857030030
|
| Hospital Charge Code |
192110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$14,694.37 |
| Rate for Payer: Aetna Commercial |
$13,335.54
|
| Rate for Payer: Aetna Medicare |
$5,056.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4,898.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$9,074.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9,876.83
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5,814.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5,561.74
|
| Rate for Payer: Cash Price |
$9,796.25
|
| Rate for Payer: Cash Price |
$9,796.25
|
| Rate for Payer: Centivo All Commercial |
$8,595.42
|
| Rate for Payer: Cigna All Commercial |
$13,635.75
|
| Rate for Payer: CORVEL All Commercial |
$14,694.37
|
| Rate for Payer: Coventry All Commercial |
$13,904.35
|
| Rate for Payer: Encore All Commercial |
$14,544.27
|
| Rate for Payer: Frontpath All Commercial |
$14,536.37
|
| Rate for Payer: Humana ChoiceCare |
$13,646.81
|
| Rate for Payer: Humana Medicare |
$5,056.13
|
| Rate for Payer: Lucent All Commercial |
$8,595.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,220.36
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$11,850.30
|
| Rate for Payer: PHP All Commercial |
$11,983.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,162.16
|
| Rate for Payer: Sagamore Health Network All Products |
$12,197.91
|
| Rate for Payer: Signature Care EPO |
$13,114.33
|
| Rate for Payer: Signature Care PPO |
$13,904.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,430.34
|
| Rate for Payer: United Healthcare Commercial |
$12,450.72
|
| Rate for Payer: United Healthcare Medicare |
$5,056.13
|
|
|
SODIUM FLUORIDE F-18 10-200 MCI/ML 370-7,400MBQ/ML IV SOLN
|
Facility
|
IP
|
$15,800.40
|
|
|
Service Code
|
NDC 65857030030
|
| Hospital Charge Code |
192110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11,850.30 |
| Max. Negotiated Rate |
$14,694.37 |
| Rate for Payer: Aetna Commercial |
$13,651.55
|
| Rate for Payer: Cash Price |
$9,796.25
|
| Rate for Payer: Cigna All Commercial |
$13,635.75
|
| Rate for Payer: CORVEL All Commercial |
$14,694.37
|
| Rate for Payer: Coventry All Commercial |
$13,904.35
|
| Rate for Payer: Encore All Commercial |
$14,544.27
|
| Rate for Payer: Frontpath All Commercial |
$14,536.37
|
| Rate for Payer: Humana ChoiceCare |
$13,646.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,220.36
|
| Rate for Payer: PHCS All Commercial |
$11,850.30
|
| Rate for Payer: PHP All Commercial |
$11,983.02
|
| Rate for Payer: Sagamore Health Network All Products |
$12,197.91
|
| Rate for Payer: Signature Care EPO |
$13,114.33
|
| Rate for Payer: Signature Care PPO |
$13,904.35
|
| Rate for Payer: United Healthcare Commercial |
$12,450.72
|
|
|
SODIUM HYALURONATE 10 MG/ML IO SYRG
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 080651830
|
| Hospital Charge Code |
28913
|
|
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 HYALURONATE (VISCOSUP) 10 MG/ML(MW 2.4 -3.6 MILLION) IATC SYRG
|
Facility
|
OP
|
$828.13
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
179484
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$256.72 |
| Max. Negotiated Rate |
$770.16 |
| Rate for Payer: Aetna Commercial |
$698.94
|
| Rate for Payer: Aetna Medicare |
$265.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$378.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$256.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$475.60
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$517.66
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$378.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$304.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$291.50
|
| Rate for Payer: Cash Price |
$513.44
|
| Rate for Payer: Cash Price |
$513.44
|
| Rate for Payer: Centivo All Commercial |
$450.50
|
| Rate for Payer: Cigna All Commercial |
$714.68
|
| Rate for Payer: CORVEL All Commercial |
$770.16
|
| Rate for Payer: Coventry All Commercial |
$728.75
|
| Rate for Payer: Encore All Commercial |
$762.29
|
| Rate for Payer: Frontpath All Commercial |
$761.88
|
| Rate for Payer: Humana ChoiceCare |
$715.26
|
| Rate for Payer: Humana Medicare |
$265.00
|
| Rate for Payer: Lucent All Commercial |
$450.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$745.32
|
| Rate for Payer: Managed Health Services Medicaid |
$378.66
|
| Rate for Payer: MDWise Medicaid |
$378.66
|
| Rate for Payer: PHCS All Commercial |
$621.10
|
| Rate for Payer: PHP All Commercial |
$628.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$322.97
|
| Rate for Payer: Sagamore Health Network All Products |
$639.32
|
| Rate for Payer: Signature Care EPO |
$687.35
|
| Rate for Payer: Signature Care PPO |
$728.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$703.91
|
| Rate for Payer: United Healthcare Commercial |
$652.57
|
| Rate for Payer: United Healthcare Medicare |
$265.00
|
|
|
SODIUM HYALURONATE (VISCOSUP) 10 MG/ML(MW 2.4 -3.6 MILLION) IATC SYRG
|
Facility
|
IP
|
$828.13
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
179484
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$621.10 |
| Max. Negotiated Rate |
$770.16 |
| Rate for Payer: Aetna Commercial |
$715.50
|
| Rate for Payer: Cash Price |
$513.44
|
| Rate for Payer: Cigna All Commercial |
$714.68
|
| Rate for Payer: CORVEL All Commercial |
$770.16
|
| Rate for Payer: Coventry All Commercial |
$728.75
|
| Rate for Payer: Encore All Commercial |
$762.29
|
| Rate for Payer: Frontpath All Commercial |
$761.88
|
| Rate for Payer: Humana ChoiceCare |
$715.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$745.32
|
| Rate for Payer: PHCS All Commercial |
$621.10
|
| Rate for Payer: PHP All Commercial |
$628.05
|
| Rate for Payer: Sagamore Health Network All Products |
$639.32
|
| Rate for Payer: Signature Care EPO |
$687.35
|
| Rate for Payer: Signature Care PPO |
$728.75
|
| Rate for Payer: United Healthcare Commercial |
$652.57
|
|
|
SODIUM HYPOCHLORITE 0.125 % MISC SOLN
|
Facility
|
OP
|
$125.82
|
|
|
Service Code
|
NDC 00436067216
|
| Hospital Charge Code |
76720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.00 |
| Max. Negotiated Rate |
$117.01 |
| Rate for Payer: Aetna Commercial |
$106.19
|
| Rate for Payer: Aetna Medicare |
$40.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$39.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$72.26
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$78.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$46.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$44.29
|
| Rate for Payer: Cash Price |
$78.01
|
| Rate for Payer: Centivo All Commercial |
$68.44
|
| Rate for Payer: Cigna All Commercial |
$108.58
|
| Rate for Payer: CORVEL All Commercial |
$117.01
|
| Rate for Payer: Coventry All Commercial |
$110.72
|
| Rate for Payer: Encore All Commercial |
$115.82
|
| Rate for Payer: Frontpath All Commercial |
$115.75
|
| Rate for Payer: Humana ChoiceCare |
$108.67
|
| Rate for Payer: Humana Medicare |
$40.26
|
| Rate for Payer: Lucent All Commercial |
$68.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$113.24
|
| Rate for Payer: PHCS All Commercial |
$94.36
|
| Rate for Payer: PHP All Commercial |
$95.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$49.07
|
| Rate for Payer: Sagamore Health Network All Products |
$97.13
|
| Rate for Payer: Signature Care EPO |
$104.43
|
| Rate for Payer: Signature Care PPO |
$110.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$106.95
|
| Rate for Payer: United Healthcare Commercial |
$99.14
|
| Rate for Payer: United Healthcare Medicare |
$40.26
|
|
|
SODIUM HYPOCHLORITE 0.125 % MISC SOLN
|
Facility
|
IP
|
$125.82
|
|
|
Service Code
|
NDC 00436067216
|
| Hospital Charge Code |
76720
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.36 |
| Max. Negotiated Rate |
$117.01 |
| Rate for Payer: Aetna Commercial |
$108.71
|
| Rate for Payer: Cash Price |
$78.01
|
| Rate for Payer: Cigna All Commercial |
$108.58
|
| Rate for Payer: CORVEL All Commercial |
$117.01
|
| Rate for Payer: Coventry All Commercial |
$110.72
|
| Rate for Payer: Encore All Commercial |
$115.82
|
| Rate for Payer: Frontpath All Commercial |
$115.75
|
| Rate for Payer: Humana ChoiceCare |
$108.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$113.24
|
| Rate for Payer: PHCS All Commercial |
$94.36
|
| Rate for Payer: PHP All Commercial |
$95.42
|
| Rate for Payer: Sagamore Health Network All Products |
$97.13
|
| Rate for Payer: Signature Care EPO |
$104.43
|
| Rate for Payer: Signature Care PPO |
$110.72
|
| Rate for Payer: United Healthcare Commercial |
$99.14
|
|
|
SODIUM IODIDE-123 7.4 MBQ (200 MICROCI) ORAL CAP
|
Facility
|
OP
|
$595.80
|
|
|
Service Code
|
HCPCS A9516
|
| Hospital Charge Code |
4080157044
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$184.70 |
| Max. Negotiated Rate |
$554.09 |
| Rate for Payer: Aetna Commercial |
$502.86
|
| Rate for Payer: Aetna Medicare |
$190.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$184.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$342.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$372.43
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$219.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$209.72
|
| Rate for Payer: Cash Price |
$369.40
|
| Rate for Payer: Centivo All Commercial |
$324.12
|
| Rate for Payer: Cigna All Commercial |
$514.18
|
| Rate for Payer: CORVEL All Commercial |
$554.09
|
| Rate for Payer: Coventry All Commercial |
$524.30
|
| Rate for Payer: Encore All Commercial |
$548.43
|
| Rate for Payer: Frontpath All Commercial |
$548.14
|
| Rate for Payer: Humana ChoiceCare |
$514.59
|
| Rate for Payer: Humana Medicare |
$190.66
|
| Rate for Payer: Lucent All Commercial |
$324.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$536.22
|
| Rate for Payer: PHCS All Commercial |
$446.85
|
| Rate for Payer: PHP All Commercial |
$451.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$232.36
|
| Rate for Payer: Sagamore Health Network All Products |
$459.96
|
| Rate for Payer: Signature Care EPO |
$494.51
|
| Rate for Payer: Signature Care PPO |
$524.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$506.43
|
| Rate for Payer: United Healthcare Commercial |
$469.49
|
| Rate for Payer: United Healthcare Medicare |
$190.66
|
|
|
SODIUM IODIDE-123 7.4 MBQ (200 MICROCI) ORAL CAP
|
Facility
|
IP
|
$595.80
|
|
|
Service Code
|
HCPCS A9516
|
| Hospital Charge Code |
4080157044
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$446.85 |
| Max. Negotiated Rate |
$554.09 |
| Rate for Payer: Aetna Commercial |
$514.77
|
| Rate for Payer: Cash Price |
$369.40
|
| Rate for Payer: Cigna All Commercial |
$514.18
|
| Rate for Payer: CORVEL All Commercial |
$554.09
|
| Rate for Payer: Coventry All Commercial |
$524.30
|
| Rate for Payer: Encore All Commercial |
$548.43
|
| Rate for Payer: Frontpath All Commercial |
$548.14
|
| Rate for Payer: Humana ChoiceCare |
$514.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$536.22
|
| Rate for Payer: PHCS All Commercial |
$446.85
|
| Rate for Payer: PHP All Commercial |
$451.85
|
| Rate for Payer: Sagamore Health Network All Products |
$459.96
|
| Rate for Payer: Signature Care EPO |
$494.51
|
| Rate for Payer: Signature Care PPO |
$524.30
|
| Rate for Payer: United Healthcare Commercial |
$469.49
|
|
|
SODIUM NITRITE-SOD THIOSULFATE 300 MG/10 ML- 12.5 GRAM/50 ML IV SOLN
|
Facility
|
OP
|
$984.90
|
|
|
Service Code
|
NDC 60267081200
|
| Hospital Charge Code |
109784
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$915.96 |
| Rate for Payer: Aetna Commercial |
$831.26
|
| Rate for Payer: Aetna Medicare |
$315.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$305.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$565.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$615.66
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$362.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$346.68
|
| Rate for Payer: Cash Price |
$610.64
|
| Rate for Payer: Cash Price |
$610.64
|
| Rate for Payer: Centivo All Commercial |
$535.79
|
| Rate for Payer: Cigna All Commercial |
$849.97
|
| Rate for Payer: CORVEL All Commercial |
$915.96
|
| Rate for Payer: Coventry All Commercial |
$866.71
|
| Rate for Payer: Encore All Commercial |
$906.60
|
| Rate for Payer: Frontpath All Commercial |
$906.11
|
| Rate for Payer: Humana ChoiceCare |
$850.66
|
| Rate for Payer: Humana Medicare |
$315.17
|
| Rate for Payer: Lucent All Commercial |
$535.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$886.41
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$738.67
|
| Rate for Payer: PHP All Commercial |
$746.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$384.11
|
| Rate for Payer: Sagamore Health Network All Products |
$760.34
|
| Rate for Payer: Signature Care EPO |
$817.47
|
| Rate for Payer: Signature Care PPO |
$866.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$837.16
|
| Rate for Payer: United Healthcare Commercial |
$776.10
|
| Rate for Payer: United Healthcare Medicare |
$315.17
|
|
|
SODIUM NITRITE-SOD THIOSULFATE 300 MG/10 ML- 12.5 GRAM/50 ML IV SOLN
|
Facility
|
IP
|
$984.90
|
|
|
Service Code
|
NDC 60267081200
|
| Hospital Charge Code |
109784
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$738.67 |
| Max. Negotiated Rate |
$915.96 |
| Rate for Payer: Aetna Commercial |
$850.95
|
| Rate for Payer: Cash Price |
$610.64
|
| Rate for Payer: Cigna All Commercial |
$849.97
|
| Rate for Payer: CORVEL All Commercial |
$915.96
|
| Rate for Payer: Coventry All Commercial |
$866.71
|
| Rate for Payer: Encore All Commercial |
$906.60
|
| Rate for Payer: Frontpath All Commercial |
$906.11
|
| Rate for Payer: Humana ChoiceCare |
$850.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$886.41
|
| Rate for Payer: PHCS All Commercial |
$738.67
|
| Rate for Payer: PHP All Commercial |
$746.95
|
| Rate for Payer: Sagamore Health Network All Products |
$760.34
|
| Rate for Payer: Signature Care EPO |
$817.47
|
| Rate for Payer: Signature Care PPO |
$866.71
|
| Rate for Payer: United Healthcare Commercial |
$776.10
|
|
|
SODIUM PERTECHNETATE TC 99M INJECTION
|
Facility
|
OP
|
$268.66
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
40840066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$83.28 |
| Max. Negotiated Rate |
$249.85 |
| Rate for Payer: Aetna Commercial |
$226.75
|
| Rate for Payer: Aetna Medicare |
$85.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$83.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$154.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$167.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$98.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$94.57
|
| Rate for Payer: Cash Price |
$166.57
|
| Rate for Payer: Centivo All Commercial |
$146.15
|
| Rate for Payer: Cigna All Commercial |
$231.85
|
| Rate for Payer: CORVEL All Commercial |
$249.85
|
| Rate for Payer: Coventry All Commercial |
$236.42
|
| Rate for Payer: Encore All Commercial |
$247.30
|
| Rate for Payer: Frontpath All Commercial |
$247.17
|
| Rate for Payer: Humana ChoiceCare |
$232.04
|
| Rate for Payer: Humana Medicare |
$85.97
|
| Rate for Payer: Lucent All Commercial |
$146.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$241.79
|
| Rate for Payer: PHCS All Commercial |
$201.50
|
| Rate for Payer: PHP All Commercial |
$203.75
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$104.78
|
| Rate for Payer: Sagamore Health Network All Products |
$207.41
|
| Rate for Payer: Signature Care EPO |
$222.99
|
| Rate for Payer: Signature Care PPO |
$236.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$228.36
|
| Rate for Payer: United Healthcare Commercial |
$211.70
|
| Rate for Payer: United Healthcare Medicare |
$85.97
|
|
|
SODIUM PERTECHNETATE TC 99M INJECTION
|
Facility
|
IP
|
$268.66
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
40840066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$201.50 |
| Max. Negotiated Rate |
$249.85 |
| Rate for Payer: Aetna Commercial |
$232.12
|
| Rate for Payer: Cash Price |
$166.57
|
| Rate for Payer: Cigna All Commercial |
$231.85
|
| Rate for Payer: CORVEL All Commercial |
$249.85
|
| Rate for Payer: Coventry All Commercial |
$236.42
|
| Rate for Payer: Encore All Commercial |
$247.30
|
| Rate for Payer: Frontpath All Commercial |
$247.17
|
| Rate for Payer: Humana ChoiceCare |
$232.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$241.79
|
| Rate for Payer: PHCS All Commercial |
$201.50
|
| Rate for Payer: PHP All Commercial |
$203.75
|
| Rate for Payer: Sagamore Health Network All Products |
$207.41
|
| Rate for Payer: Signature Care EPO |
$222.99
|
| Rate for Payer: Signature Care PPO |
$236.42
|
| Rate for Payer: United Healthcare Commercial |
$211.70
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN
|
Facility
|
IP
|
$137.83
|
|
|
Service Code
|
NDC 63323017005
|
| Hospital Charge Code |
7351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.37 |
| Max. Negotiated Rate |
$128.18 |
| Rate for Payer: Aetna Commercial |
$119.09
|
| Rate for Payer: Cash Price |
$85.45
|
| Rate for Payer: Cigna All Commercial |
$118.95
|
| Rate for Payer: CORVEL All Commercial |
$128.18
|
| Rate for Payer: Coventry All Commercial |
$121.29
|
| Rate for Payer: Encore All Commercial |
$126.87
|
| Rate for Payer: Frontpath All Commercial |
$126.80
|
| Rate for Payer: Humana ChoiceCare |
$119.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$124.05
|
| Rate for Payer: PHCS All Commercial |
$103.37
|
| Rate for Payer: PHP All Commercial |
$104.53
|
| Rate for Payer: Sagamore Health Network All Products |
$106.40
|
| Rate for Payer: Signature Care EPO |
$114.40
|
| Rate for Payer: Signature Care PPO |
$121.29
|
| Rate for Payer: United Healthcare Commercial |
$108.61
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN
|
Facility
|
OP
|
$137.83
|
|
|
Service Code
|
NDC 63323017005
|
| Hospital Charge Code |
7351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$128.18 |
| Rate for Payer: Aetna Commercial |
$116.33
|
| Rate for Payer: Aetna Medicare |
$44.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$42.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$79.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$86.16
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$50.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$48.52
|
| Rate for Payer: Cash Price |
$85.45
|
| Rate for Payer: Cash Price |
$85.45
|
| Rate for Payer: Centivo All Commercial |
$74.98
|
| Rate for Payer: Cigna All Commercial |
$118.95
|
| Rate for Payer: CORVEL All Commercial |
$128.18
|
| Rate for Payer: Coventry All Commercial |
$121.29
|
| Rate for Payer: Encore All Commercial |
$126.87
|
| Rate for Payer: Frontpath All Commercial |
$126.80
|
| Rate for Payer: Humana ChoiceCare |
$119.04
|
| Rate for Payer: Humana Medicare |
$44.11
|
| Rate for Payer: Lucent All Commercial |
$74.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$124.05
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$103.37
|
| Rate for Payer: PHP All Commercial |
$104.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$53.75
|
| Rate for Payer: Sagamore Health Network All Products |
$106.40
|
| Rate for Payer: Signature Care EPO |
$114.40
|
| Rate for Payer: Signature Care PPO |
$121.29
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$117.16
|
| Rate for Payer: United Healthcare Commercial |
$108.61
|
| Rate for Payer: United Healthcare Medicare |
$44.11
|
|
