|
POTASSIUM CHLORIDE 20 MEQ ORAL TBTQ
|
Facility
OP
|
$2.28
|
|
|
Service Code
|
NDC 00245531901
|
| Hospital Charge Code |
35943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna Commercial |
$1.93
|
| Rate for Payer: Aetna Medicare |
$0.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.43
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.83
|
| Rate for Payer: Cash Price |
$1.41
|
| Rate for Payer: Centivo All Commercial |
$1.16
|
| 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: Humana Medicare |
$1.16
|
| Rate for Payer: Lucent All Commercial |
$1.16
|
| 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: Plain Church Group Ministry All Commercial |
$0.89
|
| 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: Three Rivers Preferred All Commercial |
$1.94
|
| Rate for Payer: United Healthcare Commercial |
$1.80
|
| Rate for Payer: United Healthcare Medicare |
$0.75
|
|
|
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN
|
Facility
IP
|
$64.12
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
6429
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.09 |
| Max. Negotiated Rate |
$59.63 |
| Rate for Payer: Aetna Commercial |
$55.40
|
| Rate for Payer: Cash Price |
$39.75
|
| Rate for Payer: Cigna All Commercial |
$55.34
|
| Rate for Payer: CORVEL All Commercial |
$59.63
|
| Rate for Payer: Coventry All Commercial |
$56.43
|
| Rate for Payer: Encore All Commercial |
$59.02
|
| Rate for Payer: Frontpath All Commercial |
$58.99
|
| Rate for Payer: Humana ChoiceCare |
$55.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$57.71
|
| Rate for Payer: PHCS All Commercial |
$48.09
|
| Rate for Payer: PHP All Commercial |
$48.63
|
| Rate for Payer: Sagamore Health Network All Products |
$49.50
|
| Rate for Payer: Signature Care EPO |
$53.22
|
| Rate for Payer: Signature Care PPO |
$56.43
|
| Rate for Payer: United Healthcare Commercial |
$50.53
|
|
|
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN
|
Facility
OP
|
$64.12
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
6429
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.16 |
| Max. Negotiated Rate |
$59.63 |
| Rate for Payer: Aetna Commercial |
$54.12
|
| Rate for Payer: Aetna Medicare |
$21.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$36.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$40.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$24.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$23.28
|
| Rate for Payer: Cash Price |
$39.75
|
| Rate for Payer: Centivo All Commercial |
$32.70
|
| Rate for Payer: Cigna All Commercial |
$55.34
|
| Rate for Payer: CORVEL All Commercial |
$59.63
|
| Rate for Payer: Coventry All Commercial |
$56.43
|
| Rate for Payer: Encore All Commercial |
$59.02
|
| Rate for Payer: Frontpath All Commercial |
$58.99
|
| Rate for Payer: Humana ChoiceCare |
$55.38
|
| Rate for Payer: Humana Medicare |
$32.70
|
| Rate for Payer: Lucent All Commercial |
$32.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$57.71
|
| Rate for Payer: PHCS All Commercial |
$48.09
|
| Rate for Payer: PHP All Commercial |
$48.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$25.01
|
| Rate for Payer: Sagamore Health Network All Products |
$49.50
|
| Rate for Payer: Signature Care EPO |
$53.22
|
| Rate for Payer: Signature Care PPO |
$56.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$54.50
|
| Rate for Payer: United Healthcare Commercial |
$50.53
|
| Rate for Payer: United Healthcare Medicare |
$21.16
|
|
|
POTASSIUM CHLORIDE-D5-0.9%NACL 20 MEQ/L IV SOLP
|
Facility
OP
|
$77.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
9795
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.41 |
| Max. Negotiated Rate |
$71.61 |
| Rate for Payer: Aetna Commercial |
$64.99
|
| Rate for Payer: Aetna Medicare |
$25.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$25.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$44.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$48.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$29.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.95
|
| Rate for Payer: Cash Price |
$47.74
|
| Rate for Payer: Centivo All Commercial |
$39.27
|
| Rate for Payer: Cigna All Commercial |
$66.45
|
| Rate for Payer: CORVEL All Commercial |
$71.61
|
| Rate for Payer: Coventry All Commercial |
$67.76
|
| Rate for Payer: Encore All Commercial |
$70.88
|
| Rate for Payer: Frontpath All Commercial |
$70.84
|
| Rate for Payer: Humana ChoiceCare |
$66.50
|
| Rate for Payer: Humana Medicare |
$39.27
|
| Rate for Payer: Lucent All Commercial |
$39.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$69.30
|
| Rate for Payer: PHCS All Commercial |
$57.75
|
| Rate for Payer: PHP All Commercial |
$58.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$30.03
|
| Rate for Payer: Sagamore Health Network All Products |
$59.44
|
| Rate for Payer: Signature Care EPO |
$63.91
|
| Rate for Payer: Signature Care PPO |
$67.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$65.45
|
| Rate for Payer: United Healthcare Commercial |
$60.68
|
| Rate for Payer: United Healthcare Medicare |
$25.41
|
|
|
POTASSIUM CHLORIDE-D5-0.9%NACL 20 MEQ/L IV SOLP
|
Facility
IP
|
$77.00
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
9795
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.75 |
| Max. Negotiated Rate |
$71.61 |
| Rate for Payer: Aetna Commercial |
$66.53
|
| Rate for Payer: Cash Price |
$47.74
|
| Rate for Payer: Cigna All Commercial |
$66.45
|
| Rate for Payer: CORVEL All Commercial |
$71.61
|
| Rate for Payer: Coventry All Commercial |
$67.76
|
| Rate for Payer: Encore All Commercial |
$70.88
|
| Rate for Payer: Frontpath All Commercial |
$70.84
|
| Rate for Payer: Humana ChoiceCare |
$66.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$69.30
|
| Rate for Payer: PHCS All Commercial |
$57.75
|
| Rate for Payer: PHP All Commercial |
$58.40
|
| Rate for Payer: Sagamore Health Network All Products |
$59.44
|
| Rate for Payer: Signature Care EPO |
$63.91
|
| Rate for Payer: Signature Care PPO |
$67.76
|
| Rate for Payer: United Healthcare Commercial |
$60.68
|
|
|
POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML IV PGBK
|
Facility
OP
|
$37.10
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.24 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: Aetna Commercial |
$31.31
|
| Rate for Payer: Aetna Medicare |
$12.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$21.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.47
|
| Rate for Payer: Cash Price |
$23.00
|
| Rate for Payer: Centivo All Commercial |
$18.92
|
| Rate for Payer: Cigna All Commercial |
$32.02
|
| Rate for Payer: CORVEL All Commercial |
$34.50
|
| Rate for Payer: Coventry All Commercial |
$32.65
|
| Rate for Payer: Encore All Commercial |
$34.15
|
| Rate for Payer: Frontpath All Commercial |
$34.13
|
| Rate for Payer: Humana ChoiceCare |
$32.04
|
| Rate for Payer: Humana Medicare |
$18.92
|
| Rate for Payer: Lucent All Commercial |
$18.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.39
|
| Rate for Payer: PHCS All Commercial |
$27.82
|
| Rate for Payer: PHP All Commercial |
$28.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.47
|
| Rate for Payer: Sagamore Health Network All Products |
$28.64
|
| Rate for Payer: Signature Care EPO |
$30.79
|
| Rate for Payer: Signature Care PPO |
$32.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.54
|
| Rate for Payer: United Healthcare Commercial |
$29.23
|
| Rate for Payer: United Healthcare Medicare |
$12.24
|
|
|
POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML IV PGBK
|
Facility
IP
|
$37.10
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11076
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.82 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: Aetna Commercial |
$32.05
|
| Rate for Payer: Cash Price |
$23.00
|
| Rate for Payer: Cigna All Commercial |
$32.02
|
| Rate for Payer: CORVEL All Commercial |
$34.50
|
| Rate for Payer: Coventry All Commercial |
$32.65
|
| Rate for Payer: Encore All Commercial |
$34.15
|
| Rate for Payer: Frontpath All Commercial |
$34.13
|
| Rate for Payer: Humana ChoiceCare |
$32.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.39
|
| Rate for Payer: PHCS All Commercial |
$27.82
|
| Rate for Payer: PHP All Commercial |
$28.14
|
| Rate for Payer: Sagamore Health Network All Products |
$28.64
|
| Rate for Payer: Signature Care EPO |
$30.79
|
| Rate for Payer: Signature Care PPO |
$32.65
|
| Rate for Payer: United Healthcare Commercial |
$29.23
|
|
|
POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML IV PGBK (CAMERON)
|
Facility
IP
|
$37.10
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
14011076
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.82 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: Aetna Commercial |
$32.05
|
| Rate for Payer: Cash Price |
$23.00
|
| Rate for Payer: Cigna All Commercial |
$32.02
|
| Rate for Payer: CORVEL All Commercial |
$34.50
|
| Rate for Payer: Coventry All Commercial |
$32.65
|
| Rate for Payer: Encore All Commercial |
$34.15
|
| Rate for Payer: Frontpath All Commercial |
$34.13
|
| Rate for Payer: Humana ChoiceCare |
$32.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.39
|
| Rate for Payer: PHCS All Commercial |
$27.82
|
| Rate for Payer: PHP All Commercial |
$28.14
|
| Rate for Payer: Sagamore Health Network All Products |
$28.64
|
| Rate for Payer: Signature Care EPO |
$30.79
|
| Rate for Payer: Signature Care PPO |
$32.65
|
| Rate for Payer: United Healthcare Commercial |
$29.23
|
|
|
POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML IV PGBK (CAMERON)
|
Facility
OP
|
$37.10
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
14011076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.24 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: Aetna Commercial |
$31.31
|
| Rate for Payer: Aetna Medicare |
$12.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$21.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.47
|
| Rate for Payer: Cash Price |
$23.00
|
| Rate for Payer: Centivo All Commercial |
$18.92
|
| Rate for Payer: Cigna All Commercial |
$32.02
|
| Rate for Payer: CORVEL All Commercial |
$34.50
|
| Rate for Payer: Coventry All Commercial |
$32.65
|
| Rate for Payer: Encore All Commercial |
$34.15
|
| Rate for Payer: Frontpath All Commercial |
$34.13
|
| Rate for Payer: Humana ChoiceCare |
$32.04
|
| Rate for Payer: Humana Medicare |
$18.92
|
| Rate for Payer: Lucent All Commercial |
$18.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.39
|
| Rate for Payer: PHCS All Commercial |
$27.82
|
| Rate for Payer: PHP All Commercial |
$28.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.47
|
| Rate for Payer: Sagamore Health Network All Products |
$28.64
|
| Rate for Payer: Signature Care EPO |
$30.79
|
| Rate for Payer: Signature Care PPO |
$32.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$31.54
|
| Rate for Payer: United Healthcare Commercial |
$29.23
|
| Rate for Payer: United Healthcare Medicare |
$12.24
|
|
|
POTASSIUM CHLORIDE IN WATER 40 MEQ/100 ML IV PGBK
|
Facility
IP
|
$27.30
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11079
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$25.39 |
| Rate for Payer: Aetna Commercial |
$23.59
|
| Rate for Payer: Cash Price |
$16.93
|
| Rate for Payer: Cigna All Commercial |
$23.56
|
| Rate for Payer: CORVEL All Commercial |
$25.39
|
| Rate for Payer: Coventry All Commercial |
$24.02
|
| Rate for Payer: Encore All Commercial |
$25.13
|
| Rate for Payer: Frontpath All Commercial |
$25.12
|
| Rate for Payer: Humana ChoiceCare |
$23.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.57
|
| Rate for Payer: PHCS All Commercial |
$20.48
|
| Rate for Payer: PHP All Commercial |
$20.70
|
| Rate for Payer: Sagamore Health Network All Products |
$21.08
|
| Rate for Payer: Signature Care EPO |
$22.66
|
| Rate for Payer: Signature Care PPO |
$24.02
|
| Rate for Payer: United Healthcare Commercial |
$21.51
|
|
|
POTASSIUM CHLORIDE IN WATER 40 MEQ/100 ML IV PGBK
|
Facility
OP
|
$27.30
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11079
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.01 |
| Max. Negotiated Rate |
$25.39 |
| Rate for Payer: Aetna Commercial |
$23.04
|
| Rate for Payer: Aetna Medicare |
$9.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$15.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.91
|
| Rate for Payer: Cash Price |
$16.93
|
| Rate for Payer: Centivo All Commercial |
$13.92
|
| Rate for Payer: Cigna All Commercial |
$23.56
|
| Rate for Payer: CORVEL All Commercial |
$25.39
|
| Rate for Payer: Coventry All Commercial |
$24.02
|
| Rate for Payer: Encore All Commercial |
$25.13
|
| Rate for Payer: Frontpath All Commercial |
$25.12
|
| Rate for Payer: Humana ChoiceCare |
$23.58
|
| Rate for Payer: Humana Medicare |
$13.92
|
| Rate for Payer: Lucent All Commercial |
$13.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.57
|
| Rate for Payer: PHCS All Commercial |
$20.48
|
| Rate for Payer: PHP All Commercial |
$20.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.65
|
| Rate for Payer: Sagamore Health Network All Products |
$21.08
|
| Rate for Payer: Signature Care EPO |
$22.66
|
| Rate for Payer: Signature Care PPO |
$24.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.20
|
| Rate for Payer: United Healthcare Commercial |
$21.51
|
| Rate for Payer: United Healthcare Medicare |
$9.01
|
|
|
POTASSIUM CHLORIDE IN WATER 40 MEQ/100 ML IV PGBK (CAMERON)
|
Facility
IP
|
$27.30
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
14011079
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$25.39 |
| Rate for Payer: Aetna Commercial |
$23.59
|
| Rate for Payer: Cash Price |
$16.93
|
| Rate for Payer: Cigna All Commercial |
$23.56
|
| Rate for Payer: CORVEL All Commercial |
$25.39
|
| Rate for Payer: Coventry All Commercial |
$24.02
|
| Rate for Payer: Encore All Commercial |
$25.13
|
| Rate for Payer: Frontpath All Commercial |
$25.12
|
| Rate for Payer: Humana ChoiceCare |
$23.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.57
|
| Rate for Payer: PHCS All Commercial |
$20.48
|
| Rate for Payer: PHP All Commercial |
$20.70
|
| Rate for Payer: Sagamore Health Network All Products |
$21.08
|
| Rate for Payer: Signature Care EPO |
$22.66
|
| Rate for Payer: Signature Care PPO |
$24.02
|
| Rate for Payer: United Healthcare Commercial |
$21.51
|
|
|
POTASSIUM CHLORIDE IN WATER 40 MEQ/100 ML IV PGBK (CAMERON)
|
Facility
OP
|
$27.30
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
14011079
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.01 |
| Max. Negotiated Rate |
$25.39 |
| Rate for Payer: Aetna Commercial |
$23.04
|
| Rate for Payer: Aetna Medicare |
$9.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$15.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.91
|
| Rate for Payer: Cash Price |
$16.93
|
| Rate for Payer: Centivo All Commercial |
$13.92
|
| Rate for Payer: Cigna All Commercial |
$23.56
|
| Rate for Payer: CORVEL All Commercial |
$25.39
|
| Rate for Payer: Coventry All Commercial |
$24.02
|
| Rate for Payer: Encore All Commercial |
$25.13
|
| Rate for Payer: Frontpath All Commercial |
$25.12
|
| Rate for Payer: Humana ChoiceCare |
$23.58
|
| Rate for Payer: Humana Medicare |
$13.92
|
| Rate for Payer: Lucent All Commercial |
$13.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.57
|
| Rate for Payer: PHCS All Commercial |
$20.48
|
| Rate for Payer: PHP All Commercial |
$20.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.65
|
| Rate for Payer: Sagamore Health Network All Products |
$21.08
|
| Rate for Payer: Signature Care EPO |
$22.66
|
| Rate for Payer: Signature Care PPO |
$24.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.20
|
| Rate for Payer: United Healthcare Commercial |
$21.51
|
| Rate for Payer: United Healthcare Medicare |
$9.01
|
|
|
POTASSIUM IODIDE 130 MG ORAL TAB
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
NDC 51803000110
|
| Hospital Charge Code |
13024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
POTASSIUM IODIDE 130 MG ORAL TAB
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
NDC 51803000110
|
| Hospital Charge Code |
13024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.94
|
|
|
POTASSIUM PHOSPHATE M-/D-BASIC 3 MMOL/ML IV SOLN
|
Facility
OP
|
$103.53
|
|
|
Service Code
|
NDC 00409729501
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.16 |
| Max. Negotiated Rate |
$96.28 |
| Rate for Payer: Aetna Commercial |
$87.38
|
| Rate for Payer: Aetna Medicare |
$34.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$59.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$64.72
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$39.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$37.58
|
| Rate for Payer: Cash Price |
$64.19
|
| Rate for Payer: Cash Price |
$64.19
|
| Rate for Payer: Centivo All Commercial |
$52.80
|
| Rate for Payer: Cigna All Commercial |
$89.35
|
| Rate for Payer: CORVEL All Commercial |
$96.28
|
| Rate for Payer: Coventry All Commercial |
$91.11
|
| Rate for Payer: Encore All Commercial |
$95.30
|
| Rate for Payer: Frontpath All Commercial |
$95.25
|
| Rate for Payer: Humana ChoiceCare |
$89.42
|
| Rate for Payer: Humana Medicare |
$52.80
|
| Rate for Payer: Lucent All Commercial |
$52.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$93.18
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$77.65
|
| Rate for Payer: PHP All Commercial |
$78.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.38
|
| Rate for Payer: Sagamore Health Network All Products |
$79.93
|
| Rate for Payer: Signature Care EPO |
$85.93
|
| Rate for Payer: Signature Care PPO |
$91.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$88.00
|
| Rate for Payer: United Healthcare Commercial |
$81.58
|
| Rate for Payer: United Healthcare Medicare |
$34.16
|
|
|
POTASSIUM PHOSPHATE M-/D-BASIC 3 MMOL/ML IV SOLN
|
Facility
IP
|
$103.53
|
|
|
Service Code
|
NDC 00409729501
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.65 |
| Max. Negotiated Rate |
$96.28 |
| Rate for Payer: Aetna Commercial |
$89.45
|
| Rate for Payer: Cash Price |
$64.19
|
| Rate for Payer: Cigna All Commercial |
$89.35
|
| Rate for Payer: CORVEL All Commercial |
$96.28
|
| Rate for Payer: Coventry All Commercial |
$91.11
|
| Rate for Payer: Encore All Commercial |
$95.30
|
| Rate for Payer: Frontpath All Commercial |
$95.25
|
| Rate for Payer: Humana ChoiceCare |
$89.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$93.18
|
| Rate for Payer: PHCS All Commercial |
$77.65
|
| Rate for Payer: PHP All Commercial |
$78.52
|
| Rate for Payer: Sagamore Health Network All Products |
$79.93
|
| Rate for Payer: Signature Care EPO |
$85.93
|
| Rate for Payer: Signature Care PPO |
$91.11
|
| Rate for Payer: United Healthcare Commercial |
$81.58
|
|
|
PR 1ST HOSPITAL IP/OBS CARE HIGH MDM 75 MINUTES
|
Professional
|
$322.12
|
|
|
Service Code
|
CPT 99223
|
| Hospital Charge Code |
z99223
|
| Min. Negotiated Rate |
$150.83 |
| Max. Negotiated Rate |
$280.64 |
| Rate for Payer: Aetna Medicare |
$165.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$205.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$205.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$189.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$181.59
|
| Rate for Payer: Cash Price |
$199.71
|
| Rate for Payer: Cash Price |
$199.71
|
| Rate for Payer: Coventry All Commercial |
$198.10
|
| Rate for Payer: Frontpath All Commercial |
$202.26
|
| Rate for Payer: Humana ChoiceCare |
$150.83
|
| Rate for Payer: Humana Medicare |
$165.08
|
| Rate for Payer: Lucent All Commercial |
$280.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$206.00
|
| Rate for Payer: PHCS All Commercial |
$241.59
|
| Rate for Payer: PHP All Commercial |
$165.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$165.08
|
| Rate for Payer: Signature Care EPO |
$166.88
|
| Rate for Payer: Signature Care PPO |
$166.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$198.00
|
| Rate for Payer: United Healthcare Commercial |
$183.99
|
| Rate for Payer: United Healthcare Medicare |
$165.08
|
|
|
PR 1ST HOSPITAL IP/OBS CARE MODERATE MDM 55 MINUTES
|
Professional
|
$240.86
|
|
|
Service Code
|
CPT 99222
|
| Hospital Charge Code |
z99222
|
| Min. Negotiated Rate |
$108.16 |
| Max. Negotiated Rate |
$209.86 |
| Rate for Payer: Aetna Medicare |
$123.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$139.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$139.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$141.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$135.80
|
| Rate for Payer: Cash Price |
$149.33
|
| Rate for Payer: Cash Price |
$149.33
|
| Rate for Payer: Coventry All Commercial |
$148.14
|
| Rate for Payer: Frontpath All Commercial |
$138.08
|
| Rate for Payer: Humana ChoiceCare |
$108.16
|
| Rate for Payer: Humana Medicare |
$123.45
|
| Rate for Payer: Lucent All Commercial |
$209.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$139.00
|
| Rate for Payer: PHCS All Commercial |
$180.64
|
| Rate for Payer: PHP All Commercial |
$124.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$123.45
|
| Rate for Payer: Signature Care EPO |
$118.15
|
| Rate for Payer: Signature Care PPO |
$118.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$133.00
|
| Rate for Payer: United Healthcare Commercial |
$124.94
|
| Rate for Payer: United Healthcare Medicare |
$123.45
|
|
|
PR 1ST HOSPITAL IP/OBS CARE SF/LOW MDM 40 MINUTES
|
Professional
|
$152.58
|
|
|
Service Code
|
CPT 99221
|
| Hospital Charge Code |
z99221
|
| Min. Negotiated Rate |
$65.12 |
| Max. Negotiated Rate |
$132.94 |
| Rate for Payer: Aetna Medicare |
$78.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$97.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$97.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$89.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$86.02
|
| Rate for Payer: Cash Price |
$94.60
|
| Rate for Payer: Cash Price |
$94.60
|
| Rate for Payer: Coventry All Commercial |
$93.84
|
| Rate for Payer: Frontpath All Commercial |
$103.00
|
| Rate for Payer: Humana ChoiceCare |
$65.12
|
| Rate for Payer: Humana Medicare |
$78.20
|
| Rate for Payer: Lucent All Commercial |
$132.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$102.00
|
| Rate for Payer: PHCS All Commercial |
$114.44
|
| Rate for Payer: PHP All Commercial |
$78.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$78.20
|
| Rate for Payer: Signature Care EPO |
$83.19
|
| Rate for Payer: Signature Care PPO |
$83.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$98.00
|
| Rate for Payer: United Healthcare Commercial |
$91.56
|
| Rate for Payer: United Healthcare Medicare |
$78.20
|
|
|
PR 4VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE
|
Professional
|
$295.65
|
|
|
Service Code
|
CPT 90649
|
| Hospital Charge Code |
z90649
|
| Min. Negotiated Rate |
$170.00 |
| Max. Negotiated Rate |
$295.65 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$176.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$176.00
|
| Rate for Payer: Frontpath All Commercial |
$170.00
|
| Rate for Payer: Humana ChoiceCare |
$182.45
|
| Rate for Payer: PHP All Commercial |
$295.65
|
| Rate for Payer: United Healthcare Commercial |
$192.05
|
|
|
PR 9VHPV VACC 2/3 DOSE SCHED IM USE
|
Professional
|
$376.28
|
|
|
Service Code
|
CPT 90651
|
| Hospital Charge Code |
z90651
|
| Min. Negotiated Rate |
$255.00 |
| Max. Negotiated Rate |
$376.28 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$255.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$255.00
|
| Rate for Payer: Frontpath All Commercial |
$297.60
|
| Rate for Payer: Humana ChoiceCare |
$306.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$376.28
|
| Rate for Payer: PHP All Commercial |
$295.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$376.28
|
| Rate for Payer: United Healthcare Commercial |
$322.38
|
|
|
PR ABDOM PARACENTESIS DX/THER W IMAGING GUIDANCE
|
Professional
|
$538.78
|
|
|
Service Code
|
CPT 49083
|
| Hospital Charge Code |
z49083
|
| Min. Negotiated Rate |
$99.54 |
| Max. Negotiated Rate |
$404.08 |
| Rate for Payer: Aetna Medicare |
$99.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$358.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$358.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$114.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$109.49
|
| Rate for Payer: Cash Price |
$334.04
|
| Rate for Payer: Cash Price |
$334.04
|
| Rate for Payer: Coventry All Commercial |
$119.45
|
| Rate for Payer: Frontpath All Commercial |
$136.71
|
| Rate for Payer: Humana ChoiceCare |
$122.84
|
| Rate for Payer: Humana Medicare |
$99.54
|
| Rate for Payer: Lucent All Commercial |
$169.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$149.00
|
| Rate for Payer: PHCS All Commercial |
$404.08
|
| Rate for Payer: PHP All Commercial |
$169.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$99.54
|
| Rate for Payer: Signature Care EPO |
$319.26
|
| Rate for Payer: Signature Care PPO |
$319.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$139.00
|
| Rate for Payer: United Healthcare Commercial |
$135.59
|
| Rate for Payer: United Healthcare Medicare |
$99.54
|
|
|
PR ACOUSTIC IMMIT TEST TYMPANOMETRY/ACOUST REFLEX/DECAY
|
Professional
|
$60.48
|
|
|
Service Code
|
CPT 92570
|
| Hospital Charge Code |
z92570
|
| Min. Negotiated Rate |
$27.91 |
| Max. Negotiated Rate |
$47.45 |
| Rate for Payer: Aetna Medicare |
$27.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$37.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$37.66
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$32.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$30.70
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Coventry All Commercial |
$33.49
|
| Rate for Payer: Frontpath All Commercial |
$32.33
|
| Rate for Payer: Humana ChoiceCare |
$35.03
|
| Rate for Payer: Humana Medicare |
$27.91
|
| Rate for Payer: Lucent All Commercial |
$47.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$36.00
|
| Rate for Payer: PHCS All Commercial |
$45.36
|
| Rate for Payer: PHP All Commercial |
$39.49
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$27.91
|
| Rate for Payer: Signature Care EPO |
$33.15
|
| Rate for Payer: Signature Care PPO |
$33.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$33.00
|
| Rate for Payer: United Healthcare Commercial |
$35.69
|
| Rate for Payer: United Healthcare Medicare |
$27.91
|
|
|
PR ACOUSTIC REFLEX TESTING
|
Professional
|
$28.84
|
|
|
Service Code
|
CPT 92568
|
| Hospital Charge Code |
z92568
|
| Min. Negotiated Rate |
$14.47 |
| Max. Negotiated Rate |
$24.60 |
| Rate for Payer: Aetna Medicare |
$14.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$15.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$16.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.92
|
| Rate for Payer: Cash Price |
$17.88
|
| Rate for Payer: Cash Price |
$17.88
|
| Rate for Payer: Coventry All Commercial |
$17.36
|
| Rate for Payer: Frontpath All Commercial |
$16.74
|
| Rate for Payer: Humana ChoiceCare |
$16.04
|
| Rate for Payer: Humana Medicare |
$14.47
|
| Rate for Payer: Lucent All Commercial |
$24.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.00
|
| Rate for Payer: PHCS All Commercial |
$21.63
|
| Rate for Payer: PHP All Commercial |
$20.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.47
|
| Rate for Payer: Signature Care EPO |
$16.15
|
| Rate for Payer: Signature Care PPO |
$16.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.00
|
| Rate for Payer: United Healthcare Commercial |
$21.19
|
| Rate for Payer: United Healthcare Medicare |
$14.47
|
|
