|
SODIUM ZIRCONIUM CYCLOSILICATE 5 G ORAL PWPK
|
Facility
|
OP
|
$148.88
|
|
|
Service Code
|
NDC 00310110539
|
| Hospital Charge Code |
185534
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.15 |
| Max. Negotiated Rate |
$138.45 |
| Rate for Payer: Aetna Commercial |
$125.65
|
| Rate for Payer: Aetna Medicare |
$47.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$46.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$85.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$93.06
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$54.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$52.40
|
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Centivo All Commercial |
$80.99
|
| Rate for Payer: Cigna All Commercial |
$128.48
|
| Rate for Payer: CORVEL All Commercial |
$138.45
|
| Rate for Payer: Coventry All Commercial |
$131.01
|
| Rate for Payer: Encore All Commercial |
$137.04
|
| Rate for Payer: Frontpath All Commercial |
$136.97
|
| Rate for Payer: Humana ChoiceCare |
$128.58
|
| Rate for Payer: Humana Medicare |
$47.64
|
| Rate for Payer: Lucent All Commercial |
$80.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$133.99
|
| Rate for Payer: PHCS All Commercial |
$111.66
|
| Rate for Payer: PHP All Commercial |
$112.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$58.06
|
| Rate for Payer: Sagamore Health Network All Products |
$114.93
|
| Rate for Payer: Signature Care EPO |
$123.57
|
| Rate for Payer: Signature Care PPO |
$131.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$126.54
|
| Rate for Payer: United Healthcare Commercial |
$117.31
|
| Rate for Payer: United Healthcare Medicare |
$47.64
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 5 G ORAL PWPK
|
Facility
|
IP
|
$148.88
|
|
|
Service Code
|
NDC 00310110539
|
| Hospital Charge Code |
185534
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$111.66 |
| Max. Negotiated Rate |
$138.45 |
| Rate for Payer: Aetna Commercial |
$128.63
|
| Rate for Payer: Cash Price |
$92.30
|
| Rate for Payer: Cigna All Commercial |
$128.48
|
| Rate for Payer: CORVEL All Commercial |
$138.45
|
| Rate for Payer: Coventry All Commercial |
$131.01
|
| Rate for Payer: Encore All Commercial |
$137.04
|
| Rate for Payer: Frontpath All Commercial |
$136.97
|
| Rate for Payer: Humana ChoiceCare |
$128.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$133.99
|
| Rate for Payer: PHCS All Commercial |
$111.66
|
| Rate for Payer: PHP All Commercial |
$112.91
|
| Rate for Payer: Sagamore Health Network All Products |
$114.93
|
| Rate for Payer: Signature Care EPO |
$123.57
|
| Rate for Payer: Signature Care PPO |
$131.01
|
| Rate for Payer: United Healthcare Commercial |
$117.31
|
|
|
SOD PHOS DI, MONO-K PHOS MONO 250 MG ORAL TAB
|
Facility
|
IP
|
$1.65
|
|
|
Service Code
|
NDC 64980010401
|
| Hospital Charge Code |
11067
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Aetna Commercial |
$1.42
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna All Commercial |
$1.42
|
| Rate for Payer: CORVEL All Commercial |
$1.53
|
| Rate for Payer: Coventry All Commercial |
$1.45
|
| Rate for Payer: Encore All Commercial |
$1.51
|
| Rate for Payer: Frontpath All Commercial |
$1.51
|
| Rate for Payer: Humana ChoiceCare |
$1.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.48
|
| Rate for Payer: PHCS All Commercial |
$1.23
|
| Rate for Payer: PHP All Commercial |
$1.25
|
| Rate for Payer: Sagamore Health Network All Products |
$1.27
|
| Rate for Payer: Signature Care EPO |
$1.37
|
| Rate for Payer: Signature Care PPO |
$1.45
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
|
|
SOD PHOS DI, MONO-K PHOS MONO 250 MG ORAL TAB
|
Facility
|
OP
|
$1.65
|
|
|
Service Code
|
NDC 64980010401
|
| Hospital Charge Code |
11067
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.53 |
| Rate for Payer: Aetna Commercial |
$1.39
|
| Rate for Payer: Aetna Medicare |
$0.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.58
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Centivo All Commercial |
$0.89
|
| Rate for Payer: Cigna All Commercial |
$1.42
|
| Rate for Payer: CORVEL All Commercial |
$1.53
|
| Rate for Payer: Coventry All Commercial |
$1.45
|
| Rate for Payer: Encore All Commercial |
$1.51
|
| Rate for Payer: Frontpath All Commercial |
$1.51
|
| Rate for Payer: Humana ChoiceCare |
$1.42
|
| Rate for Payer: Humana Medicare |
$0.53
|
| Rate for Payer: Lucent All Commercial |
$0.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.48
|
| Rate for Payer: PHCS All Commercial |
$1.23
|
| Rate for Payer: PHP All Commercial |
$1.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.64
|
| Rate for Payer: Sagamore Health Network All Products |
$1.27
|
| Rate for Payer: Signature Care EPO |
$1.37
|
| Rate for Payer: Signature Care PPO |
$1.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.40
|
| Rate for Payer: United Healthcare Commercial |
$1.30
|
| Rate for Payer: United Healthcare Medicare |
$0.53
|
|
|
SORBITOL 70 % MISC SOLN
|
Facility
|
IP
|
$26.46
|
|
|
Service Code
|
NDC 46287050030
|
| Hospital Charge Code |
7413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.84 |
| Max. Negotiated Rate |
$24.61 |
| Rate for Payer: Aetna Commercial |
$22.86
|
| Rate for Payer: Cash Price |
$16.41
|
| Rate for Payer: Cigna All Commercial |
$22.83
|
| Rate for Payer: CORVEL All Commercial |
$24.61
|
| Rate for Payer: Coventry All Commercial |
$23.28
|
| Rate for Payer: Encore All Commercial |
$24.36
|
| Rate for Payer: Frontpath All Commercial |
$24.34
|
| Rate for Payer: Humana ChoiceCare |
$22.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.81
|
| Rate for Payer: PHCS All Commercial |
$19.84
|
| Rate for Payer: PHP All Commercial |
$20.07
|
| Rate for Payer: Sagamore Health Network All Products |
$20.43
|
| Rate for Payer: Signature Care EPO |
$21.96
|
| Rate for Payer: Signature Care PPO |
$23.28
|
| Rate for Payer: United Healthcare Commercial |
$20.85
|
|
|
SORBITOL 70 % MISC SOLN
|
Facility
|
OP
|
$26.46
|
|
|
Service Code
|
NDC 46287050030
|
| Hospital Charge Code |
7413
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.20 |
| Max. Negotiated Rate |
$24.61 |
| Rate for Payer: Aetna Commercial |
$22.33
|
| Rate for Payer: Aetna Medicare |
$8.47
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$15.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.54
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.31
|
| Rate for Payer: Cash Price |
$16.41
|
| Rate for Payer: Centivo All Commercial |
$14.39
|
| Rate for Payer: Cigna All Commercial |
$22.83
|
| Rate for Payer: CORVEL All Commercial |
$24.61
|
| Rate for Payer: Coventry All Commercial |
$23.28
|
| Rate for Payer: Encore All Commercial |
$24.36
|
| Rate for Payer: Frontpath All Commercial |
$24.34
|
| Rate for Payer: Humana ChoiceCare |
$22.85
|
| Rate for Payer: Humana Medicare |
$8.47
|
| Rate for Payer: Lucent All Commercial |
$14.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.81
|
| Rate for Payer: PHCS All Commercial |
$19.84
|
| Rate for Payer: PHP All Commercial |
$20.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.32
|
| Rate for Payer: Sagamore Health Network All Products |
$20.43
|
| Rate for Payer: Signature Care EPO |
$21.96
|
| Rate for Payer: Signature Care PPO |
$23.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22.49
|
| Rate for Payer: United Healthcare Commercial |
$20.85
|
| Rate for Payer: United Healthcare Medicare |
$8.47
|
|
|
SORBITOL-MANNITOL-XANTHAN GUM ORAL LIQD
|
Facility
|
IP
|
$52.50
|
|
|
Service Code
|
NDC 15137002127
|
| Hospital Charge Code |
192690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.38 |
| Max. Negotiated Rate |
$48.83 |
| Rate for Payer: Aetna Commercial |
$45.36
|
| Rate for Payer: Cash Price |
$32.55
|
| Rate for Payer: Cigna All Commercial |
$45.31
|
| Rate for Payer: CORVEL All Commercial |
$48.83
|
| Rate for Payer: Coventry All Commercial |
$46.20
|
| Rate for Payer: Encore All Commercial |
$48.33
|
| Rate for Payer: Frontpath All Commercial |
$48.30
|
| Rate for Payer: Humana ChoiceCare |
$45.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$47.25
|
| Rate for Payer: PHCS All Commercial |
$39.38
|
| Rate for Payer: PHP All Commercial |
$39.82
|
| Rate for Payer: Sagamore Health Network All Products |
$40.53
|
| Rate for Payer: Signature Care EPO |
$43.58
|
| Rate for Payer: Signature Care PPO |
$46.20
|
| Rate for Payer: United Healthcare Commercial |
$41.37
|
|
|
SORBITOL-MANNITOL-XANTHAN GUM ORAL LIQD
|
Facility
|
OP
|
$52.50
|
|
|
Service Code
|
NDC 15137002127
|
| Hospital Charge Code |
192690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$48.83 |
| Rate for Payer: Aetna Commercial |
$44.31
|
| Rate for Payer: Aetna Medicare |
$16.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$30.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$32.82
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$19.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.48
|
| Rate for Payer: Cash Price |
$32.55
|
| Rate for Payer: Cash Price |
$32.55
|
| Rate for Payer: Centivo All Commercial |
$28.56
|
| Rate for Payer: Cigna All Commercial |
$45.31
|
| Rate for Payer: CORVEL All Commercial |
$48.83
|
| Rate for Payer: Coventry All Commercial |
$46.20
|
| Rate for Payer: Encore All Commercial |
$48.33
|
| Rate for Payer: Frontpath All Commercial |
$48.30
|
| Rate for Payer: Humana ChoiceCare |
$45.34
|
| Rate for Payer: Humana Medicare |
$16.80
|
| Rate for Payer: Lucent All Commercial |
$28.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$47.25
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$39.38
|
| Rate for Payer: PHP All Commercial |
$39.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$20.48
|
| Rate for Payer: Sagamore Health Network All Products |
$40.53
|
| Rate for Payer: Signature Care EPO |
$43.58
|
| Rate for Payer: Signature Care PPO |
$46.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$44.62
|
| Rate for Payer: United Healthcare Commercial |
$41.37
|
| Rate for Payer: United Healthcare Medicare |
$16.80
|
|
|
SOTALOL 120 MG ORAL TAB
|
Facility
|
OP
|
$2.49
|
|
|
Service Code
|
NDC 00093106001
|
| Hospital Charge Code |
15723
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna Commercial |
$2.10
|
| Rate for Payer: Aetna Medicare |
$0.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.88
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Centivo All Commercial |
$1.36
|
| Rate for Payer: Cigna All Commercial |
$2.15
|
| Rate for Payer: CORVEL All Commercial |
$2.32
|
| Rate for Payer: Coventry All Commercial |
$2.19
|
| Rate for Payer: Encore All Commercial |
$2.29
|
| Rate for Payer: Frontpath All Commercial |
$2.29
|
| Rate for Payer: Humana ChoiceCare |
$2.15
|
| Rate for Payer: Humana Medicare |
$0.80
|
| Rate for Payer: Lucent All Commercial |
$1.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.24
|
| Rate for Payer: PHCS All Commercial |
$1.87
|
| Rate for Payer: PHP All Commercial |
$1.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.97
|
| Rate for Payer: Sagamore Health Network All Products |
$1.92
|
| Rate for Payer: Signature Care EPO |
$2.07
|
| Rate for Payer: Signature Care PPO |
$2.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.12
|
| Rate for Payer: United Healthcare Commercial |
$1.96
|
| Rate for Payer: United Healthcare Medicare |
$0.80
|
|
|
SOTALOL 120 MG ORAL TAB
|
Facility
|
IP
|
$2.49
|
|
|
Service Code
|
NDC 00093106001
|
| Hospital Charge Code |
15723
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna Commercial |
$2.15
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Cigna All Commercial |
$2.15
|
| Rate for Payer: CORVEL All Commercial |
$2.32
|
| Rate for Payer: Coventry All Commercial |
$2.19
|
| Rate for Payer: Encore All Commercial |
$2.29
|
| Rate for Payer: Frontpath All Commercial |
$2.29
|
| Rate for Payer: Humana ChoiceCare |
$2.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.24
|
| Rate for Payer: PHCS All Commercial |
$1.87
|
| Rate for Payer: PHP All Commercial |
$1.89
|
| Rate for Payer: Sagamore Health Network All Products |
$1.92
|
| Rate for Payer: Signature Care EPO |
$2.07
|
| Rate for Payer: Signature Care PPO |
$2.19
|
| Rate for Payer: United Healthcare Commercial |
$1.96
|
|
|
SOTALOL 80 MG ORAL TAB
|
Facility
|
OP
|
$5.05
|
|
|
Service Code
|
NDC 00904714361
|
| Hospital Charge Code |
11421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Aetna Commercial |
$4.27
|
| Rate for Payer: Aetna Medicare |
$1.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.78
|
| Rate for Payer: Cash Price |
$3.13
|
| Rate for Payer: Centivo All Commercial |
$2.75
|
| Rate for Payer: Cigna All Commercial |
$4.36
|
| Rate for Payer: CORVEL All Commercial |
$4.70
|
| Rate for Payer: Coventry All Commercial |
$4.45
|
| Rate for Payer: Encore All Commercial |
$4.65
|
| Rate for Payer: Frontpath All Commercial |
$4.65
|
| Rate for Payer: Humana ChoiceCare |
$4.37
|
| Rate for Payer: Humana Medicare |
$1.62
|
| Rate for Payer: Lucent All Commercial |
$2.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.55
|
| Rate for Payer: PHCS All Commercial |
$3.79
|
| Rate for Payer: PHP All Commercial |
$3.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.97
|
| Rate for Payer: Sagamore Health Network All Products |
$3.90
|
| Rate for Payer: Signature Care EPO |
$4.19
|
| Rate for Payer: Signature Care PPO |
$4.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.30
|
| Rate for Payer: United Healthcare Commercial |
$3.98
|
| Rate for Payer: United Healthcare Medicare |
$1.62
|
|
|
SOTALOL 80 MG ORAL TAB
|
Facility
|
IP
|
$5.05
|
|
|
Service Code
|
NDC 00904714361
|
| Hospital Charge Code |
11421
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$4.70 |
| Rate for Payer: Aetna Commercial |
$4.37
|
| Rate for Payer: Cash Price |
$3.13
|
| Rate for Payer: Cigna All Commercial |
$4.36
|
| Rate for Payer: CORVEL All Commercial |
$4.70
|
| Rate for Payer: Coventry All Commercial |
$4.45
|
| Rate for Payer: Encore All Commercial |
$4.65
|
| Rate for Payer: Frontpath All Commercial |
$4.65
|
| Rate for Payer: Humana ChoiceCare |
$4.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.55
|
| Rate for Payer: PHCS All Commercial |
$3.79
|
| Rate for Payer: PHP All Commercial |
$3.83
|
| Rate for Payer: Sagamore Health Network All Products |
$3.90
|
| Rate for Payer: Signature Care EPO |
$4.19
|
| Rate for Payer: Signature Care PPO |
$4.45
|
| Rate for Payer: United Healthcare Commercial |
$3.98
|
|
|
SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC;
|
Facility
|
OP
|
$318.54
|
|
|
Service Code
|
CPT 62270
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$318.54 |
| Max. Negotiated Rate |
$318.54 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$318.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$318.54
|
| Rate for Payer: Managed Health Services Medicaid |
$318.54
|
| Rate for Payer: MDWise Medicaid |
$318.54
|
|
|
SPINAL PUNCTURE, THERAPEUTIC, FOR DRAINAGE OF CEREBROSPINAL FLUID (BY NEEDLE OR CATHETER);
|
Facility
|
OP
|
$318.54
|
|
|
Service Code
|
CPT 62272
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$318.54 |
| Max. Negotiated Rate |
$318.54 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$318.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$318.54
|
| Rate for Payer: Managed Health Services Medicaid |
$318.54
|
| Rate for Payer: MDWise Medicaid |
$318.54
|
|
|
SPIRONOLACTONE 25 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 63739054410
|
| Hospital Charge Code |
7437
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
SPIRONOLACTONE 25 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 63739054410
|
| Hospital Charge Code |
7437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) IV SYRG
|
Facility
|
OP
|
$171.64
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
121308
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.21 |
| Max. Negotiated Rate |
$159.63 |
| Rate for Payer: Aetna Commercial |
$144.86
|
| Rate for Payer: Aetna Medicare |
$54.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$53.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$98.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$107.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$63.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$60.42
|
| Rate for Payer: Cash Price |
$106.42
|
| Rate for Payer: Centivo All Commercial |
$93.37
|
| Rate for Payer: Cigna All Commercial |
$148.13
|
| Rate for Payer: CORVEL All Commercial |
$159.63
|
| Rate for Payer: Coventry All Commercial |
$151.04
|
| Rate for Payer: Encore All Commercial |
$157.99
|
| Rate for Payer: Frontpath All Commercial |
$157.91
|
| Rate for Payer: Humana ChoiceCare |
$148.25
|
| Rate for Payer: Humana Medicare |
$54.92
|
| Rate for Payer: Lucent All Commercial |
$93.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$154.48
|
| Rate for Payer: PHCS All Commercial |
$128.73
|
| Rate for Payer: PHP All Commercial |
$130.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$66.94
|
| Rate for Payer: Sagamore Health Network All Products |
$132.51
|
| Rate for Payer: Signature Care EPO |
$142.46
|
| Rate for Payer: Signature Care PPO |
$151.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$145.89
|
| Rate for Payer: United Healthcare Commercial |
$135.25
|
| Rate for Payer: United Healthcare Medicare |
$54.92
|
|
|
SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) IV SYRG
|
Facility
|
IP
|
$171.64
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
121308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$128.73 |
| Max. Negotiated Rate |
$159.63 |
| Rate for Payer: Aetna Commercial |
$148.30
|
| Rate for Payer: Cash Price |
$106.42
|
| Rate for Payer: Cigna All Commercial |
$148.13
|
| Rate for Payer: CORVEL All Commercial |
$159.63
|
| Rate for Payer: Coventry All Commercial |
$151.04
|
| Rate for Payer: Encore All Commercial |
$157.99
|
| Rate for Payer: Frontpath All Commercial |
$157.91
|
| Rate for Payer: Humana ChoiceCare |
$148.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$154.48
|
| Rate for Payer: PHCS All Commercial |
$128.73
|
| Rate for Payer: PHP All Commercial |
$130.17
|
| Rate for Payer: Sagamore Health Network All Products |
$132.51
|
| Rate for Payer: Signature Care EPO |
$142.46
|
| Rate for Payer: Signature Care PPO |
$151.04
|
| Rate for Payer: United Healthcare Commercial |
$135.25
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ S.O. (CAMERON)
|
Facility
|
IP
|
$67.90
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
14017536
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.92 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$58.67
|
| Rate for Payer: Cash Price |
$42.10
|
| Rate for Payer: Cigna All Commercial |
$58.60
|
| Rate for Payer: CORVEL All Commercial |
$63.15
|
| Rate for Payer: Coventry All Commercial |
$59.75
|
| Rate for Payer: Encore All Commercial |
$62.50
|
| Rate for Payer: Frontpath All Commercial |
$62.47
|
| Rate for Payer: Humana ChoiceCare |
$58.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.11
|
| Rate for Payer: PHCS All Commercial |
$50.92
|
| Rate for Payer: PHP All Commercial |
$51.50
|
| Rate for Payer: Sagamore Health Network All Products |
$52.42
|
| Rate for Payer: Signature Care EPO |
$56.36
|
| Rate for Payer: Signature Care PPO |
$59.75
|
| Rate for Payer: United Healthcare Commercial |
$53.51
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ S.O. (CAMERON)
|
Facility
|
OP
|
$67.90
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
14017536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.05 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$57.31
|
| Rate for Payer: Aetna Medicare |
$21.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$38.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$42.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$24.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$23.90
|
| Rate for Payer: Cash Price |
$42.10
|
| Rate for Payer: Centivo All Commercial |
$36.94
|
| Rate for Payer: Cigna All Commercial |
$58.60
|
| Rate for Payer: CORVEL All Commercial |
$63.15
|
| Rate for Payer: Coventry All Commercial |
$59.75
|
| Rate for Payer: Encore All Commercial |
$62.50
|
| Rate for Payer: Frontpath All Commercial |
$62.47
|
| Rate for Payer: Humana ChoiceCare |
$58.65
|
| Rate for Payer: Humana Medicare |
$21.73
|
| Rate for Payer: Lucent All Commercial |
$36.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.11
|
| Rate for Payer: PHCS All Commercial |
$50.92
|
| Rate for Payer: PHP All Commercial |
$51.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$26.48
|
| Rate for Payer: Sagamore Health Network All Products |
$52.42
|
| Rate for Payer: Signature Care EPO |
$56.36
|
| Rate for Payer: Signature Care PPO |
$59.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$57.72
|
| Rate for Payer: United Healthcare Commercial |
$53.51
|
| Rate for Payer: United Healthcare Medicare |
$21.73
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLN
|
Facility
|
IP
|
$67.90
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
7536
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.92 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$58.67
|
| Rate for Payer: Cash Price |
$42.10
|
| Rate for Payer: Cigna All Commercial |
$58.60
|
| Rate for Payer: CORVEL All Commercial |
$63.15
|
| Rate for Payer: Coventry All Commercial |
$59.75
|
| Rate for Payer: Encore All Commercial |
$62.50
|
| Rate for Payer: Frontpath All Commercial |
$62.47
|
| Rate for Payer: Humana ChoiceCare |
$58.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.11
|
| Rate for Payer: PHCS All Commercial |
$50.92
|
| Rate for Payer: PHP All Commercial |
$51.50
|
| Rate for Payer: Sagamore Health Network All Products |
$52.42
|
| Rate for Payer: Signature Care EPO |
$56.36
|
| Rate for Payer: Signature Care PPO |
$59.75
|
| Rate for Payer: United Healthcare Commercial |
$53.51
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLN
|
Facility
|
OP
|
$67.90
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
7536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.05 |
| Max. Negotiated Rate |
$63.15 |
| Rate for Payer: Aetna Commercial |
$57.31
|
| Rate for Payer: Aetna Medicare |
$21.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$38.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$42.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$24.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$23.90
|
| Rate for Payer: Cash Price |
$42.10
|
| Rate for Payer: Centivo All Commercial |
$36.94
|
| Rate for Payer: Cigna All Commercial |
$58.60
|
| Rate for Payer: CORVEL All Commercial |
$63.15
|
| Rate for Payer: Coventry All Commercial |
$59.75
|
| Rate for Payer: Encore All Commercial |
$62.50
|
| Rate for Payer: Frontpath All Commercial |
$62.47
|
| Rate for Payer: Humana ChoiceCare |
$58.65
|
| Rate for Payer: Humana Medicare |
$21.73
|
| Rate for Payer: Lucent All Commercial |
$36.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$61.11
|
| Rate for Payer: PHCS All Commercial |
$50.92
|
| Rate for Payer: PHP All Commercial |
$51.50
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$26.48
|
| Rate for Payer: Sagamore Health Network All Products |
$52.42
|
| Rate for Payer: Signature Care EPO |
$56.36
|
| Rate for Payer: Signature Care PPO |
$59.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$57.72
|
| Rate for Payer: United Healthcare Commercial |
$53.51
|
| Rate for Payer: United Healthcare Medicare |
$21.73
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML SYRINGE S.O.
|
Facility
|
OP
|
$171.64
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
140121308
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.21 |
| Max. Negotiated Rate |
$159.63 |
| Rate for Payer: Aetna Commercial |
$144.86
|
| Rate for Payer: Aetna Medicare |
$54.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$53.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$98.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$107.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$63.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$60.42
|
| Rate for Payer: Cash Price |
$106.42
|
| Rate for Payer: Centivo All Commercial |
$93.37
|
| Rate for Payer: Cigna All Commercial |
$148.13
|
| Rate for Payer: CORVEL All Commercial |
$159.63
|
| Rate for Payer: Coventry All Commercial |
$151.04
|
| Rate for Payer: Encore All Commercial |
$157.99
|
| Rate for Payer: Frontpath All Commercial |
$157.91
|
| Rate for Payer: Humana ChoiceCare |
$148.25
|
| Rate for Payer: Humana Medicare |
$54.92
|
| Rate for Payer: Lucent All Commercial |
$93.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$154.48
|
| Rate for Payer: PHCS All Commercial |
$128.73
|
| Rate for Payer: PHP All Commercial |
$130.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$66.94
|
| Rate for Payer: Sagamore Health Network All Products |
$132.51
|
| Rate for Payer: Signature Care EPO |
$142.46
|
| Rate for Payer: Signature Care PPO |
$151.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$145.89
|
| Rate for Payer: United Healthcare Commercial |
$135.25
|
| Rate for Payer: United Healthcare Medicare |
$54.92
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML SYRINGE S.O.
|
Facility
|
IP
|
$171.64
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
140121308
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$128.73 |
| Max. Negotiated Rate |
$159.63 |
| Rate for Payer: Aetna Commercial |
$148.30
|
| Rate for Payer: Cash Price |
$106.42
|
| Rate for Payer: Cigna All Commercial |
$148.13
|
| Rate for Payer: CORVEL All Commercial |
$159.63
|
| Rate for Payer: Coventry All Commercial |
$151.04
|
| Rate for Payer: Encore All Commercial |
$157.99
|
| Rate for Payer: Frontpath All Commercial |
$157.91
|
| Rate for Payer: Humana ChoiceCare |
$148.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$154.48
|
| Rate for Payer: PHCS All Commercial |
$128.73
|
| Rate for Payer: PHP All Commercial |
$130.17
|
| Rate for Payer: Sagamore Health Network All Products |
$132.51
|
| Rate for Payer: Signature Care EPO |
$142.46
|
| Rate for Payer: Signature Care PPO |
$151.04
|
| Rate for Payer: United Healthcare Commercial |
$135.25
|
|
|
SUCCINYLCHOLINE-SOD CL,ISO(PF) 200 MG/10 ML (20 MG/ML) IV SYRG
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
177642
|
|
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
|
|
