|
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG
|
Facility
OP
|
$1,023.64
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
195321
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$265.87 |
| Max. Negotiated Rate |
$951.99 |
| Rate for Payer: Aetna Commercial |
$863.95
|
| Rate for Payer: Aetna Commercial |
$1,047.10
|
| Rate for Payer: Aetna Medicare |
$409.41
|
| Rate for Payer: Aetna Medicare |
$337.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$337.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$409.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$587.88
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$712.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$639.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$775.52
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$265.87
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$265.87
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$388.47
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$470.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$371.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$450.35
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cash Price |
$634.66
|
| Rate for Payer: Cash Price |
$634.66
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Centivo All Commercial |
$632.73
|
| Rate for Payer: Centivo All Commercial |
$522.06
|
| Rate for Payer: Cigna All Commercial |
$883.40
|
| Rate for Payer: Cigna All Commercial |
$1,070.67
|
| Rate for Payer: CORVEL All Commercial |
$1,153.80
|
| Rate for Payer: CORVEL All Commercial |
$951.99
|
| Rate for Payer: Coventry All Commercial |
$1,091.76
|
| Rate for Payer: Coventry All Commercial |
$900.80
|
| Rate for Payer: Encore All Commercial |
$1,142.01
|
| Rate for Payer: Encore All Commercial |
$942.26
|
| Rate for Payer: Frontpath All Commercial |
$1,141.39
|
| Rate for Payer: Frontpath All Commercial |
$941.75
|
| Rate for Payer: Humana ChoiceCare |
$884.12
|
| Rate for Payer: Humana ChoiceCare |
$1,071.54
|
| Rate for Payer: Humana Medicare |
$522.06
|
| Rate for Payer: Humana Medicare |
$632.73
|
| Rate for Payer: Lucent All Commercial |
$632.73
|
| Rate for Payer: Lucent All Commercial |
$522.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$921.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,116.58
|
| Rate for Payer: Managed Health Services Medicaid |
$265.87
|
| Rate for Payer: Managed Health Services Medicaid |
$265.87
|
| Rate for Payer: MDWise Medicaid |
$265.87
|
| Rate for Payer: MDWise Medicaid |
$265.87
|
| Rate for Payer: PHCS All Commercial |
$930.48
|
| Rate for Payer: PHCS All Commercial |
$767.73
|
| Rate for Payer: PHP All Commercial |
$776.33
|
| Rate for Payer: PHP All Commercial |
$940.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$483.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$399.22
|
| Rate for Payer: Sagamore Health Network All Products |
$790.25
|
| Rate for Payer: Sagamore Health Network All Products |
$957.77
|
| Rate for Payer: Signature Care EPO |
$849.62
|
| Rate for Payer: Signature Care EPO |
$1,029.73
|
| Rate for Payer: Signature Care PPO |
$1,091.76
|
| Rate for Payer: Signature Care PPO |
$900.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$870.09
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,054.54
|
| Rate for Payer: United Healthcare Commercial |
$806.63
|
| Rate for Payer: United Healthcare Commercial |
$977.62
|
| Rate for Payer: United Healthcare Medicare |
$337.80
|
| Rate for Payer: United Healthcare Medicare |
$409.41
|
|
|
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG
|
Facility
IP
|
$1,023.64
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
195321
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$767.73 |
| Max. Negotiated Rate |
$951.99 |
| Rate for Payer: Aetna Commercial |
$884.42
|
| Rate for Payer: Aetna Commercial |
$1,071.91
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cash Price |
$634.66
|
| Rate for Payer: Cigna All Commercial |
$1,070.67
|
| Rate for Payer: Cigna All Commercial |
$883.40
|
| Rate for Payer: CORVEL All Commercial |
$951.99
|
| Rate for Payer: CORVEL All Commercial |
$1,153.80
|
| Rate for Payer: Coventry All Commercial |
$900.80
|
| Rate for Payer: Coventry All Commercial |
$1,091.76
|
| Rate for Payer: Encore All Commercial |
$942.26
|
| Rate for Payer: Encore All Commercial |
$1,142.01
|
| Rate for Payer: Frontpath All Commercial |
$1,141.39
|
| Rate for Payer: Frontpath All Commercial |
$941.75
|
| Rate for Payer: Humana ChoiceCare |
$1,071.54
|
| Rate for Payer: Humana ChoiceCare |
$884.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$921.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,116.58
|
| Rate for Payer: PHCS All Commercial |
$767.73
|
| Rate for Payer: PHCS All Commercial |
$930.48
|
| Rate for Payer: PHP All Commercial |
$776.33
|
| Rate for Payer: PHP All Commercial |
$940.90
|
| Rate for Payer: Sagamore Health Network All Products |
$957.77
|
| Rate for Payer: Sagamore Health Network All Products |
$790.25
|
| Rate for Payer: Signature Care EPO |
$1,029.73
|
| Rate for Payer: Signature Care EPO |
$849.62
|
| Rate for Payer: Signature Care PPO |
$900.80
|
| Rate for Payer: Signature Care PPO |
$1,091.76
|
| Rate for Payer: United Healthcare Commercial |
$977.62
|
| Rate for Payer: United Healthcare Commercial |
$806.63
|
|
|
PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML INJ SYRG
|
Facility
OP
|
$244.30
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
113995
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.62 |
| Max. Negotiated Rate |
$227.20 |
| Rate for Payer: Aetna Commercial |
$206.19
|
| Rate for Payer: Aetna Medicare |
$80.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$80.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$140.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$152.71
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$122.94
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$92.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$88.68
|
| Rate for Payer: Cash Price |
$151.47
|
| Rate for Payer: Cash Price |
$151.47
|
| Rate for Payer: Centivo All Commercial |
$124.60
|
| Rate for Payer: Cigna All Commercial |
$210.83
|
| Rate for Payer: CORVEL All Commercial |
$227.20
|
| Rate for Payer: Coventry All Commercial |
$214.99
|
| Rate for Payer: Encore All Commercial |
$224.88
|
| Rate for Payer: Frontpath All Commercial |
$224.76
|
| Rate for Payer: Humana ChoiceCare |
$211.01
|
| Rate for Payer: Humana Medicare |
$124.60
|
| Rate for Payer: Lucent All Commercial |
$124.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$219.87
|
| Rate for Payer: Managed Health Services Medicaid |
$122.94
|
| Rate for Payer: MDWise Medicaid |
$122.94
|
| Rate for Payer: PHCS All Commercial |
$183.23
|
| Rate for Payer: PHP All Commercial |
$185.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$95.28
|
| Rate for Payer: Sagamore Health Network All Products |
$188.60
|
| Rate for Payer: Signature Care EPO |
$202.77
|
| Rate for Payer: Signature Care PPO |
$214.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$207.66
|
| Rate for Payer: United Healthcare Commercial |
$192.51
|
| Rate for Payer: United Healthcare Medicare |
$80.62
|
|
|
PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML INJ SYRG
|
Facility
IP
|
$244.30
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
113995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$183.23 |
| Max. Negotiated Rate |
$227.20 |
| Rate for Payer: Aetna Commercial |
$211.08
|
| Rate for Payer: Cash Price |
$151.47
|
| Rate for Payer: Cigna All Commercial |
$210.83
|
| Rate for Payer: CORVEL All Commercial |
$227.20
|
| Rate for Payer: Coventry All Commercial |
$214.99
|
| Rate for Payer: Encore All Commercial |
$224.88
|
| Rate for Payer: Frontpath All Commercial |
$224.76
|
| Rate for Payer: Humana ChoiceCare |
$211.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$219.87
|
| Rate for Payer: PHCS All Commercial |
$183.23
|
| Rate for Payer: PHP All Commercial |
$185.28
|
| Rate for Payer: Sagamore Health Network All Products |
$188.60
|
| Rate for Payer: Signature Care EPO |
$202.77
|
| Rate for Payer: Signature Care PPO |
$214.99
|
| Rate for Payer: United Healthcare Commercial |
$192.51
|
|
|
POLIOVIRUS VACCINE 40-8-32 UNIT/0.5 ML INJ SUSP
|
Facility
OP
|
$1,537.68
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
108127
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$507.43 |
| Max. Negotiated Rate |
$1,430.04 |
| Rate for Payer: Aetna Commercial |
$1,297.80
|
| Rate for Payer: Aetna Medicare |
$507.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$507.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$883.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$961.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$583.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$558.18
|
| Rate for Payer: Cash Price |
$953.36
|
| Rate for Payer: Centivo All Commercial |
$784.22
|
| Rate for Payer: Cigna All Commercial |
$1,327.02
|
| Rate for Payer: CORVEL All Commercial |
$1,430.04
|
| Rate for Payer: Coventry All Commercial |
$1,353.16
|
| Rate for Payer: Encore All Commercial |
$1,415.43
|
| Rate for Payer: Frontpath All Commercial |
$1,414.67
|
| Rate for Payer: Humana ChoiceCare |
$1,328.09
|
| Rate for Payer: Humana Medicare |
$784.22
|
| Rate for Payer: Lucent All Commercial |
$784.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,383.91
|
| Rate for Payer: PHCS All Commercial |
$1,153.26
|
| Rate for Payer: PHP All Commercial |
$1,166.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$599.70
|
| Rate for Payer: Sagamore Health Network All Products |
$1,187.09
|
| Rate for Payer: Signature Care EPO |
$1,276.27
|
| Rate for Payer: Signature Care PPO |
$1,353.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,307.03
|
| Rate for Payer: United Healthcare Commercial |
$1,211.69
|
| Rate for Payer: United Healthcare Medicare |
$507.43
|
|
|
POLIOVIRUS VACCINE 40-8-32 UNIT/0.5 ML INJ SUSP
|
Facility
IP
|
$1,537.68
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
108127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,153.26 |
| Max. Negotiated Rate |
$1,430.04 |
| Rate for Payer: Aetna Commercial |
$1,328.56
|
| Rate for Payer: Cash Price |
$953.36
|
| Rate for Payer: Cigna All Commercial |
$1,327.02
|
| Rate for Payer: CORVEL All Commercial |
$1,430.04
|
| Rate for Payer: Coventry All Commercial |
$1,353.16
|
| Rate for Payer: Encore All Commercial |
$1,415.43
|
| Rate for Payer: Frontpath All Commercial |
$1,414.67
|
| Rate for Payer: Humana ChoiceCare |
$1,328.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,383.91
|
| Rate for Payer: PHCS All Commercial |
$1,153.26
|
| Rate for Payer: PHP All Commercial |
$1,166.18
|
| Rate for Payer: Sagamore Health Network All Products |
$1,187.09
|
| Rate for Payer: Signature Care EPO |
$1,276.27
|
| Rate for Payer: Signature Care PPO |
$1,353.16
|
| Rate for Payer: United Healthcare Commercial |
$1,211.69
|
|
|
POLYETHYLENE GLYCOL 3350 17 G ORAL PWPK
|
Facility
IP
|
$8.39
|
|
|
Service Code
|
NDC 11523726808
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$7.80 |
| Rate for Payer: Aetna Commercial |
$7.25
|
| Rate for Payer: Cash Price |
$5.20
|
| Rate for Payer: Cigna All Commercial |
$7.24
|
| Rate for Payer: CORVEL All Commercial |
$7.80
|
| Rate for Payer: Coventry All Commercial |
$7.38
|
| Rate for Payer: Encore All Commercial |
$7.72
|
| Rate for Payer: Frontpath All Commercial |
$7.72
|
| Rate for Payer: Humana ChoiceCare |
$7.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.55
|
| Rate for Payer: PHCS All Commercial |
$6.29
|
| Rate for Payer: PHP All Commercial |
$6.36
|
| Rate for Payer: Sagamore Health Network All Products |
$6.47
|
| Rate for Payer: Signature Care EPO |
$6.96
|
| Rate for Payer: Signature Care PPO |
$7.38
|
| Rate for Payer: United Healthcare Commercial |
$6.61
|
|
|
POLYETHYLENE GLYCOL 3350 17 G ORAL PWPK
|
Facility
OP
|
$8.39
|
|
|
Service Code
|
NDC 11523726808
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$7.80 |
| Rate for Payer: Aetna Commercial |
$7.08
|
| Rate for Payer: Aetna Medicare |
$2.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.04
|
| Rate for Payer: Cash Price |
$5.20
|
| Rate for Payer: Centivo All Commercial |
$4.28
|
| Rate for Payer: Cigna All Commercial |
$7.24
|
| Rate for Payer: CORVEL All Commercial |
$7.80
|
| Rate for Payer: Coventry All Commercial |
$7.38
|
| Rate for Payer: Encore All Commercial |
$7.72
|
| Rate for Payer: Frontpath All Commercial |
$7.72
|
| Rate for Payer: Humana ChoiceCare |
$7.24
|
| Rate for Payer: Humana Medicare |
$4.28
|
| Rate for Payer: Lucent All Commercial |
$4.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.55
|
| Rate for Payer: PHCS All Commercial |
$6.29
|
| Rate for Payer: PHP All Commercial |
$6.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.27
|
| Rate for Payer: Sagamore Health Network All Products |
$6.47
|
| Rate for Payer: Signature Care EPO |
$6.96
|
| Rate for Payer: Signature Care PPO |
$7.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.13
|
| Rate for Payer: United Healthcare Commercial |
$6.61
|
| Rate for Payer: United Healthcare Medicare |
$2.77
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWD
|
Facility
OP
|
$39.98
|
|
|
Service Code
|
NDC 00536105224
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.19 |
| Max. Negotiated Rate |
$37.19 |
| Rate for Payer: Aetna Commercial |
$33.75
|
| Rate for Payer: Aetna Medicare |
$13.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$22.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.51
|
| Rate for Payer: Cash Price |
$24.79
|
| Rate for Payer: Centivo All Commercial |
$20.39
|
| Rate for Payer: Cigna All Commercial |
$34.51
|
| Rate for Payer: CORVEL All Commercial |
$37.19
|
| Rate for Payer: Coventry All Commercial |
$35.19
|
| Rate for Payer: Encore All Commercial |
$36.81
|
| Rate for Payer: Frontpath All Commercial |
$36.79
|
| Rate for Payer: Humana ChoiceCare |
$34.53
|
| Rate for Payer: Humana Medicare |
$20.39
|
| Rate for Payer: Lucent All Commercial |
$20.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.99
|
| Rate for Payer: PHCS All Commercial |
$29.99
|
| Rate for Payer: PHP All Commercial |
$30.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.59
|
| Rate for Payer: Sagamore Health Network All Products |
$30.87
|
| Rate for Payer: Signature Care EPO |
$33.19
|
| Rate for Payer: Signature Care PPO |
$35.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$33.99
|
| Rate for Payer: United Healthcare Commercial |
$31.51
|
| Rate for Payer: United Healthcare Medicare |
$13.19
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWD
|
Facility
IP
|
$39.98
|
|
|
Service Code
|
NDC 00536105224
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.99 |
| Max. Negotiated Rate |
$37.19 |
| Rate for Payer: Aetna Commercial |
$34.55
|
| Rate for Payer: Cash Price |
$24.79
|
| Rate for Payer: Cigna All Commercial |
$34.51
|
| Rate for Payer: CORVEL All Commercial |
$37.19
|
| Rate for Payer: Coventry All Commercial |
$35.19
|
| Rate for Payer: Encore All Commercial |
$36.81
|
| Rate for Payer: Frontpath All Commercial |
$36.79
|
| Rate for Payer: Humana ChoiceCare |
$34.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.99
|
| Rate for Payer: PHCS All Commercial |
$29.99
|
| Rate for Payer: PHP All Commercial |
$30.32
|
| Rate for Payer: Sagamore Health Network All Products |
$30.87
|
| Rate for Payer: Signature Care EPO |
$33.19
|
| Rate for Payer: Signature Care PPO |
$35.19
|
| Rate for Payer: United Healthcare Commercial |
$31.51
|
|
|
POLYMYXIN B SULFATE 500000 UNITS INJ SOLR
|
Facility
OP
|
$33.72
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
6393
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.13 |
| Max. Negotiated Rate |
$31.36 |
| Rate for Payer: Aetna Commercial |
$28.46
|
| Rate for Payer: Aetna Medicare |
$11.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$19.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.24
|
| Rate for Payer: Cash Price |
$20.91
|
| Rate for Payer: Centivo All Commercial |
$17.20
|
| Rate for Payer: Cigna All Commercial |
$29.10
|
| Rate for Payer: CORVEL All Commercial |
$31.36
|
| Rate for Payer: Coventry All Commercial |
$29.67
|
| Rate for Payer: Encore All Commercial |
$31.04
|
| Rate for Payer: Frontpath All Commercial |
$31.02
|
| Rate for Payer: Humana ChoiceCare |
$29.12
|
| Rate for Payer: Humana Medicare |
$17.20
|
| Rate for Payer: Lucent All Commercial |
$17.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.35
|
| Rate for Payer: PHCS All Commercial |
$25.29
|
| Rate for Payer: PHP All Commercial |
$25.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.15
|
| Rate for Payer: Sagamore Health Network All Products |
$26.03
|
| Rate for Payer: Signature Care EPO |
$27.99
|
| Rate for Payer: Signature Care PPO |
$29.67
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.66
|
| Rate for Payer: United Healthcare Commercial |
$26.57
|
| Rate for Payer: United Healthcare Medicare |
$11.13
|
|
|
POLYMYXIN B SULFATE 500000 UNITS INJ SOLR
|
Facility
IP
|
$33.72
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
6393
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.29 |
| Max. Negotiated Rate |
$31.36 |
| Rate for Payer: Aetna Commercial |
$29.13
|
| Rate for Payer: Cash Price |
$20.91
|
| Rate for Payer: Cigna All Commercial |
$29.10
|
| Rate for Payer: CORVEL All Commercial |
$31.36
|
| Rate for Payer: Coventry All Commercial |
$29.67
|
| Rate for Payer: Encore All Commercial |
$31.04
|
| Rate for Payer: Frontpath All Commercial |
$31.02
|
| Rate for Payer: Humana ChoiceCare |
$29.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.35
|
| Rate for Payer: PHCS All Commercial |
$25.29
|
| Rate for Payer: PHP All Commercial |
$25.57
|
| Rate for Payer: Sagamore Health Network All Products |
$26.03
|
| Rate for Payer: Signature Care EPO |
$27.99
|
| Rate for Payer: Signature Care PPO |
$29.67
|
| Rate for Payer: United Healthcare Commercial |
$26.57
|
|
|
POTASSIUM ACETATE 2 MEQ/ML IV SOLN
|
Facility
OP
|
$26.60
|
|
|
Service Code
|
NDC 00409818301
|
| Hospital Charge Code |
6420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.78 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$22.45
|
| Rate for Payer: Aetna Medicare |
$8.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$15.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.66
|
| Rate for Payer: Cash Price |
$16.49
|
| Rate for Payer: Cash Price |
$16.49
|
| Rate for Payer: Centivo All Commercial |
$13.57
|
| Rate for Payer: Cigna All Commercial |
$22.96
|
| Rate for Payer: CORVEL All Commercial |
$24.74
|
| Rate for Payer: Coventry All Commercial |
$23.41
|
| Rate for Payer: Encore All Commercial |
$24.49
|
| Rate for Payer: Frontpath All Commercial |
$24.47
|
| Rate for Payer: Humana ChoiceCare |
$22.97
|
| Rate for Payer: Humana Medicare |
$13.57
|
| Rate for Payer: Lucent All Commercial |
$13.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.94
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$19.95
|
| Rate for Payer: PHP All Commercial |
$20.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.37
|
| Rate for Payer: Sagamore Health Network All Products |
$20.54
|
| Rate for Payer: Signature Care EPO |
$22.08
|
| Rate for Payer: Signature Care PPO |
$23.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22.61
|
| Rate for Payer: United Healthcare Commercial |
$20.96
|
| Rate for Payer: United Healthcare Medicare |
$8.78
|
|
|
POTASSIUM ACETATE 2 MEQ/ML IV SOLN
|
Facility
IP
|
$26.60
|
|
|
Service Code
|
NDC 00409818301
|
| Hospital Charge Code |
6420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$24.74 |
| Rate for Payer: Aetna Commercial |
$22.98
|
| Rate for Payer: Cash Price |
$16.49
|
| Rate for Payer: Cigna All Commercial |
$22.96
|
| Rate for Payer: CORVEL All Commercial |
$24.74
|
| Rate for Payer: Coventry All Commercial |
$23.41
|
| Rate for Payer: Encore All Commercial |
$24.49
|
| Rate for Payer: Frontpath All Commercial |
$24.47
|
| Rate for Payer: Humana ChoiceCare |
$22.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.94
|
| Rate for Payer: PHCS All Commercial |
$19.95
|
| Rate for Payer: PHP All Commercial |
$20.17
|
| Rate for Payer: Sagamore Health Network All Products |
$20.54
|
| Rate for Payer: Signature Care EPO |
$22.08
|
| Rate for Payer: Signature Care PPO |
$23.41
|
| Rate for Payer: United Healthcare Commercial |
$20.96
|
|
|
POTASSIUM CHLORID-D5-0.45%NACL 20 MEQ/L IV SOLP
|
Facility
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
9801
|
|
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
|
|
|
POTASSIUM CHLORID-D5-0.45%NACL 20 MEQ/L IV SOLP
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
9801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$39.06 |
| Rate for Payer: Aetna Commercial |
$35.45
|
| Rate for Payer: Aetna Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$24.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.25
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Centivo All Commercial |
$21.42
|
| 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 |
$21.42
|
| Rate for Payer: Lucent All Commercial |
$21.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.80
|
| Rate for Payer: PHCS All Commercial |
$31.50
|
| Rate for Payer: PHP All Commercial |
$31.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$16.38
|
| Rate for Payer: Sagamore Health Network All Products |
$32.42
|
| Rate for Payer: Signature Care EPO |
$34.86
|
| Rate for Payer: Signature Care PPO |
$36.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.70
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$13.86
|
|
|
POTASSIUM CHLORID-D5-0.45%NACL 40 MEQ/L IV SOLP
|
Facility
IP
|
$70.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
9807
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$65.10 |
| Rate for Payer: Aetna Commercial |
$60.48
|
| Rate for Payer: Cash Price |
$43.40
|
| Rate for Payer: Cigna All Commercial |
$60.41
|
| Rate for Payer: CORVEL All Commercial |
$65.10
|
| Rate for Payer: Coventry All Commercial |
$61.60
|
| Rate for Payer: Encore All Commercial |
$64.44
|
| Rate for Payer: Frontpath All Commercial |
$64.40
|
| Rate for Payer: Humana ChoiceCare |
$60.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$63.00
|
| Rate for Payer: PHCS All Commercial |
$52.50
|
| Rate for Payer: PHP All Commercial |
$53.09
|
| Rate for Payer: Sagamore Health Network All Products |
$54.04
|
| Rate for Payer: Signature Care EPO |
$58.10
|
| Rate for Payer: Signature Care PPO |
$61.60
|
| Rate for Payer: United Healthcare Commercial |
$55.16
|
|
|
POTASSIUM CHLORID-D5-0.45%NACL 40 MEQ/L IV SOLP
|
Facility
OP
|
$70.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
9807
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$65.10 |
| Rate for Payer: Aetna Commercial |
$59.08
|
| Rate for Payer: Aetna Medicare |
$23.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$23.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$40.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$43.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.41
|
| Rate for Payer: Cash Price |
$43.40
|
| Rate for Payer: Centivo All Commercial |
$35.70
|
| Rate for Payer: Cigna All Commercial |
$60.41
|
| Rate for Payer: CORVEL All Commercial |
$65.10
|
| Rate for Payer: Coventry All Commercial |
$61.60
|
| Rate for Payer: Encore All Commercial |
$64.44
|
| Rate for Payer: Frontpath All Commercial |
$64.40
|
| Rate for Payer: Humana ChoiceCare |
$60.46
|
| Rate for Payer: Humana Medicare |
$35.70
|
| Rate for Payer: Lucent All Commercial |
$35.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$63.00
|
| Rate for Payer: PHCS All Commercial |
$52.50
|
| Rate for Payer: PHP All Commercial |
$53.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$27.30
|
| Rate for Payer: Sagamore Health Network All Products |
$54.04
|
| Rate for Payer: Signature Care EPO |
$58.10
|
| Rate for Payer: Signature Care PPO |
$61.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$59.50
|
| Rate for Payer: United Healthcare Commercial |
$55.16
|
| Rate for Payer: United Healthcare Medicare |
$23.10
|
|
|
POTASSIUM CHLORIDE 10 MEQ ORAL TBTQ
|
Facility
OP
|
$1.99
|
|
|
Service Code
|
NDC 00245531701
|
| Hospital Charge Code |
35942
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Aetna Commercial |
$1.68
|
| Rate for Payer: Aetna Medicare |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.72
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Centivo All Commercial |
$1.01
|
| Rate for Payer: Cigna All Commercial |
$1.72
|
| Rate for Payer: CORVEL All Commercial |
$1.85
|
| Rate for Payer: Coventry All Commercial |
$1.75
|
| Rate for Payer: Encore All Commercial |
$1.83
|
| Rate for Payer: Frontpath All Commercial |
$1.83
|
| Rate for Payer: Humana ChoiceCare |
$1.72
|
| Rate for Payer: Humana Medicare |
$1.01
|
| Rate for Payer: Lucent All Commercial |
$1.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.79
|
| Rate for Payer: PHCS All Commercial |
$1.49
|
| Rate for Payer: PHP All Commercial |
$1.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.78
|
| Rate for Payer: Sagamore Health Network All Products |
$1.53
|
| Rate for Payer: Signature Care EPO |
$1.65
|
| Rate for Payer: Signature Care PPO |
$1.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.69
|
| Rate for Payer: United Healthcare Commercial |
$1.57
|
| Rate for Payer: United Healthcare Medicare |
$0.66
|
|
|
POTASSIUM CHLORIDE 10 MEQ ORAL TBTQ
|
Facility
IP
|
$1.99
|
|
|
Service Code
|
NDC 00245531701
|
| Hospital Charge Code |
35942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Aetna Commercial |
$1.72
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna All Commercial |
$1.72
|
| Rate for Payer: CORVEL All Commercial |
$1.85
|
| Rate for Payer: Coventry All Commercial |
$1.75
|
| Rate for Payer: Encore All Commercial |
$1.83
|
| Rate for Payer: Frontpath All Commercial |
$1.83
|
| Rate for Payer: Humana ChoiceCare |
$1.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.79
|
| Rate for Payer: PHCS All Commercial |
$1.49
|
| Rate for Payer: PHP All Commercial |
$1.51
|
| Rate for Payer: Sagamore Health Network All Products |
$1.53
|
| Rate for Payer: Signature Care EPO |
$1.65
|
| Rate for Payer: Signature Care PPO |
$1.75
|
| Rate for Payer: United Healthcare Commercial |
$1.57
|
|
|
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQD
|
Facility
IP
|
$24.99
|
|
|
Service Code
|
NDC 81033022015
|
| Hospital Charge Code |
6432
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.74 |
| Max. Negotiated Rate |
$23.24 |
| Rate for Payer: Aetna Commercial |
$21.59
|
| Rate for Payer: Cash Price |
$15.49
|
| Rate for Payer: Cigna All Commercial |
$21.57
|
| Rate for Payer: CORVEL All Commercial |
$23.24
|
| Rate for Payer: Coventry All Commercial |
$21.99
|
| Rate for Payer: Encore All Commercial |
$23.00
|
| Rate for Payer: Frontpath All Commercial |
$22.99
|
| Rate for Payer: Humana ChoiceCare |
$21.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.49
|
| Rate for Payer: PHCS All Commercial |
$18.74
|
| Rate for Payer: PHP All Commercial |
$18.95
|
| Rate for Payer: Sagamore Health Network All Products |
$19.29
|
| Rate for Payer: Signature Care EPO |
$20.74
|
| Rate for Payer: Signature Care PPO |
$21.99
|
| Rate for Payer: United Healthcare Commercial |
$19.69
|
|
|
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQD
|
Facility
OP
|
$24.99
|
|
|
Service Code
|
NDC 81033022015
|
| Hospital Charge Code |
6432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.25 |
| Max. Negotiated Rate |
$23.24 |
| Rate for Payer: Aetna Commercial |
$21.09
|
| Rate for Payer: Aetna Medicare |
$8.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.07
|
| Rate for Payer: Cash Price |
$15.49
|
| Rate for Payer: Centivo All Commercial |
$12.74
|
| Rate for Payer: Cigna All Commercial |
$21.57
|
| Rate for Payer: CORVEL All Commercial |
$23.24
|
| Rate for Payer: Coventry All Commercial |
$21.99
|
| Rate for Payer: Encore All Commercial |
$23.00
|
| Rate for Payer: Frontpath All Commercial |
$22.99
|
| Rate for Payer: Humana ChoiceCare |
$21.58
|
| Rate for Payer: Humana Medicare |
$12.74
|
| Rate for Payer: Lucent All Commercial |
$12.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.49
|
| Rate for Payer: PHCS All Commercial |
$18.74
|
| Rate for Payer: PHP All Commercial |
$18.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.75
|
| Rate for Payer: Sagamore Health Network All Products |
$19.29
|
| Rate for Payer: Signature Care EPO |
$20.74
|
| Rate for Payer: Signature Care PPO |
$21.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.24
|
| Rate for Payer: United Healthcare Commercial |
$19.69
|
| Rate for Payer: United Healthcare Medicare |
$8.25
|
|
|
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQD
|
Facility
IP
|
$33.18
|
|
|
Service Code
|
NDC 60687062850
|
| Hospital Charge Code |
6432
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.88 |
| Max. Negotiated Rate |
$30.86 |
| Rate for Payer: Aetna Commercial |
$28.67
|
| Rate for Payer: Cash Price |
$20.57
|
| Rate for Payer: Cigna All Commercial |
$28.63
|
| Rate for Payer: CORVEL All Commercial |
$30.86
|
| Rate for Payer: Coventry All Commercial |
$29.20
|
| Rate for Payer: Encore All Commercial |
$30.54
|
| Rate for Payer: Frontpath All Commercial |
$30.53
|
| Rate for Payer: Humana ChoiceCare |
$28.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.86
|
| Rate for Payer: PHCS All Commercial |
$24.88
|
| Rate for Payer: PHP All Commercial |
$25.16
|
| Rate for Payer: Sagamore Health Network All Products |
$25.61
|
| Rate for Payer: Signature Care EPO |
$27.54
|
| Rate for Payer: Signature Care PPO |
$29.20
|
| Rate for Payer: United Healthcare Commercial |
$26.15
|
|
|
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQD
|
Facility
OP
|
$33.18
|
|
|
Service Code
|
NDC 60687062850
|
| Hospital Charge Code |
6432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.95 |
| Max. Negotiated Rate |
$30.86 |
| Rate for Payer: Aetna Commercial |
$28.00
|
| Rate for Payer: Aetna Medicare |
$10.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$19.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.59
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.04
|
| Rate for Payer: Cash Price |
$20.57
|
| Rate for Payer: Centivo All Commercial |
$16.92
|
| Rate for Payer: Cigna All Commercial |
$28.63
|
| Rate for Payer: CORVEL All Commercial |
$30.86
|
| Rate for Payer: Coventry All Commercial |
$29.20
|
| Rate for Payer: Encore All Commercial |
$30.54
|
| Rate for Payer: Frontpath All Commercial |
$30.53
|
| Rate for Payer: Humana ChoiceCare |
$28.66
|
| Rate for Payer: Humana Medicare |
$16.92
|
| Rate for Payer: Lucent All Commercial |
$16.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.86
|
| Rate for Payer: PHCS All Commercial |
$24.88
|
| Rate for Payer: PHP All Commercial |
$25.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.94
|
| Rate for Payer: Sagamore Health Network All Products |
$25.61
|
| Rate for Payer: Signature Care EPO |
$27.54
|
| Rate for Payer: Signature Care PPO |
$29.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.20
|
| Rate for Payer: United Healthcare Commercial |
$26.15
|
| Rate for Payer: United Healthcare Medicare |
$10.95
|
|
|
POTASSIUM CHLORIDE 20 MEQ ORAL TBTQ
|
Facility
IP
|
$2.28
|
|
|
Service Code
|
NDC 00245531901
|
| Hospital Charge Code |
35943
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna Commercial |
$1.97
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Cigna All Commercial |
$1.97
|
| Rate for Payer: CORVEL All Commercial |
$2.12
|
| Rate for Payer: Coventry All Commercial |
$2.01
|
| Rate for Payer: Encore All Commercial |
$2.10
|
| Rate for Payer: Frontpath All Commercial |
$2.10
|
| Rate for Payer: Humana ChoiceCare |
$1.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.05
|
| Rate for Payer: PHCS All Commercial |
$1.71
|
| Rate for Payer: PHP All Commercial |
$1.73
|
| Rate for Payer: Sagamore Health Network All Products |
$1.76
|
| Rate for Payer: Signature Care EPO |
$1.89
|
| Rate for Payer: Signature Care PPO |
$2.01
|
| Rate for Payer: United Healthcare Commercial |
$1.80
|
|
