|
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL
|
Facility
IP
|
$82.46
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.84 |
| Max. Negotiated Rate |
$76.69 |
| Rate for Payer: Aetna Commercial |
$71.25
|
| Rate for Payer: Cash Price |
$51.13
|
| Rate for Payer: Cigna All Commercial |
$71.16
|
| Rate for Payer: CORVEL All Commercial |
$76.69
|
| Rate for Payer: Coventry All Commercial |
$72.56
|
| Rate for Payer: Encore All Commercial |
$75.90
|
| Rate for Payer: Frontpath All Commercial |
$75.86
|
| Rate for Payer: Humana ChoiceCare |
$71.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.21
|
| Rate for Payer: PHCS All Commercial |
$61.84
|
| Rate for Payer: PHP All Commercial |
$62.54
|
| Rate for Payer: Sagamore Health Network All Products |
$63.66
|
| Rate for Payer: Signature Care EPO |
$68.44
|
| Rate for Payer: Signature Care PPO |
$72.56
|
| Rate for Payer: United Healthcare Commercial |
$64.98
|
|
|
TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM S.O.
|
Facility
OP
|
$246.81
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
420789
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.45 |
| Max. Negotiated Rate |
$229.54 |
| Rate for Payer: Aetna Commercial |
$208.31
|
| Rate for Payer: Aetna Medicare |
$81.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$81.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$141.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$154.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$93.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$89.59
|
| Rate for Payer: Cash Price |
$153.02
|
| Rate for Payer: Centivo All Commercial |
$125.87
|
| Rate for Payer: Cigna All Commercial |
$213.00
|
| Rate for Payer: CORVEL All Commercial |
$229.54
|
| Rate for Payer: Coventry All Commercial |
$217.20
|
| Rate for Payer: Encore All Commercial |
$227.19
|
| Rate for Payer: Frontpath All Commercial |
$227.07
|
| Rate for Payer: Humana ChoiceCare |
$213.17
|
| Rate for Payer: Humana Medicare |
$125.87
|
| Rate for Payer: Lucent All Commercial |
$125.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$222.13
|
| Rate for Payer: PHCS All Commercial |
$185.11
|
| Rate for Payer: PHP All Commercial |
$187.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$96.26
|
| Rate for Payer: Sagamore Health Network All Products |
$190.54
|
| Rate for Payer: Signature Care EPO |
$204.85
|
| Rate for Payer: Signature Care PPO |
$217.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$209.79
|
| Rate for Payer: United Healthcare Commercial |
$194.49
|
| Rate for Payer: United Healthcare Medicare |
$81.45
|
|
|
TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM S.O.
|
Facility
IP
|
$246.81
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
420789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$185.11 |
| Max. Negotiated Rate |
$229.54 |
| Rate for Payer: Aetna Commercial |
$213.25
|
| Rate for Payer: Cash Price |
$153.02
|
| Rate for Payer: Cigna All Commercial |
$213.00
|
| Rate for Payer: CORVEL All Commercial |
$229.54
|
| Rate for Payer: Coventry All Commercial |
$217.20
|
| Rate for Payer: Encore All Commercial |
$227.19
|
| Rate for Payer: Frontpath All Commercial |
$227.07
|
| Rate for Payer: Humana ChoiceCare |
$213.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$222.13
|
| Rate for Payer: PHCS All Commercial |
$185.11
|
| Rate for Payer: PHP All Commercial |
$187.18
|
| Rate for Payer: Sagamore Health Network All Products |
$190.54
|
| Rate for Payer: Signature Care EPO |
$204.85
|
| Rate for Payer: Signature Care PPO |
$217.20
|
| Rate for Payer: United Healthcare Commercial |
$194.49
|
|
|
TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM SYRG
|
Facility
OP
|
$246.81
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
119618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.45 |
| Max. Negotiated Rate |
$229.54 |
| Rate for Payer: Aetna Commercial |
$208.31
|
| Rate for Payer: Aetna Medicare |
$81.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$81.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$141.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$154.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$93.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$89.59
|
| Rate for Payer: Cash Price |
$153.02
|
| Rate for Payer: Centivo All Commercial |
$125.87
|
| Rate for Payer: Cigna All Commercial |
$213.00
|
| Rate for Payer: CORVEL All Commercial |
$229.54
|
| Rate for Payer: Coventry All Commercial |
$217.20
|
| Rate for Payer: Encore All Commercial |
$227.19
|
| Rate for Payer: Frontpath All Commercial |
$227.07
|
| Rate for Payer: Humana ChoiceCare |
$213.17
|
| Rate for Payer: Humana Medicare |
$125.87
|
| Rate for Payer: Lucent All Commercial |
$125.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$222.13
|
| Rate for Payer: PHCS All Commercial |
$185.11
|
| Rate for Payer: PHP All Commercial |
$187.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$96.26
|
| Rate for Payer: Sagamore Health Network All Products |
$190.54
|
| Rate for Payer: Signature Care EPO |
$204.85
|
| Rate for Payer: Signature Care PPO |
$217.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$209.79
|
| Rate for Payer: United Healthcare Commercial |
$194.49
|
| Rate for Payer: United Healthcare Medicare |
$81.45
|
|
|
TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM SYRG
|
Facility
IP
|
$246.81
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
119618
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$185.11 |
| Max. Negotiated Rate |
$229.54 |
| Rate for Payer: Aetna Commercial |
$213.25
|
| Rate for Payer: Cash Price |
$153.02
|
| Rate for Payer: Cigna All Commercial |
$213.00
|
| Rate for Payer: CORVEL All Commercial |
$229.54
|
| Rate for Payer: Coventry All Commercial |
$217.20
|
| Rate for Payer: Encore All Commercial |
$227.19
|
| Rate for Payer: Frontpath All Commercial |
$227.07
|
| Rate for Payer: Humana ChoiceCare |
$213.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$222.13
|
| Rate for Payer: PHCS All Commercial |
$185.11
|
| Rate for Payer: PHP All Commercial |
$187.18
|
| Rate for Payer: Sagamore Health Network All Products |
$190.54
|
| Rate for Payer: Signature Care EPO |
$204.85
|
| Rate for Payer: Signature Care PPO |
$217.20
|
| Rate for Payer: United Healthcare Commercial |
$194.49
|
|
|
TETANUS AND DIPHTHER. TOX (PF) 5 LF UNIT- 2 LF UNIT/0.5ML IM SUSP
|
Facility
IP
|
$246.81
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
119619
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$185.11 |
| Max. Negotiated Rate |
$229.54 |
| Rate for Payer: Aetna Commercial |
$213.25
|
| Rate for Payer: Cash Price |
$153.02
|
| Rate for Payer: Cigna All Commercial |
$213.00
|
| Rate for Payer: CORVEL All Commercial |
$229.54
|
| Rate for Payer: Coventry All Commercial |
$217.20
|
| Rate for Payer: Encore All Commercial |
$227.19
|
| Rate for Payer: Frontpath All Commercial |
$227.07
|
| Rate for Payer: Humana ChoiceCare |
$213.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$222.13
|
| Rate for Payer: PHCS All Commercial |
$185.11
|
| Rate for Payer: PHP All Commercial |
$187.18
|
| Rate for Payer: Sagamore Health Network All Products |
$190.54
|
| Rate for Payer: Signature Care EPO |
$204.85
|
| Rate for Payer: Signature Care PPO |
$217.20
|
| Rate for Payer: United Healthcare Commercial |
$194.49
|
|
|
TETANUS AND DIPHTHER. TOX (PF) 5 LF UNIT- 2 LF UNIT/0.5ML IM SUSP
|
Facility
OP
|
$246.81
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
119619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.45 |
| Max. Negotiated Rate |
$229.54 |
| Rate for Payer: Aetna Commercial |
$208.31
|
| Rate for Payer: Aetna Medicare |
$81.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$81.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$141.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$154.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$93.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$89.59
|
| Rate for Payer: Cash Price |
$153.02
|
| Rate for Payer: Centivo All Commercial |
$125.87
|
| Rate for Payer: Cigna All Commercial |
$213.00
|
| Rate for Payer: CORVEL All Commercial |
$229.54
|
| Rate for Payer: Coventry All Commercial |
$217.20
|
| Rate for Payer: Encore All Commercial |
$227.19
|
| Rate for Payer: Frontpath All Commercial |
$227.07
|
| Rate for Payer: Humana ChoiceCare |
$213.17
|
| Rate for Payer: Humana Medicare |
$125.87
|
| Rate for Payer: Lucent All Commercial |
$125.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$222.13
|
| Rate for Payer: PHCS All Commercial |
$185.11
|
| Rate for Payer: PHP All Commercial |
$187.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$96.26
|
| Rate for Payer: Sagamore Health Network All Products |
$190.54
|
| Rate for Payer: Signature Care EPO |
$204.85
|
| Rate for Payer: Signature Care PPO |
$217.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$209.79
|
| Rate for Payer: United Healthcare Commercial |
$194.49
|
| Rate for Payer: United Healthcare Medicare |
$81.45
|
|
|
TETANUS,DIPHTHERIA TOX PED(PF) 5-25 LF UNIT/0.5 ML IM SUSP
|
Facility
OP
|
$358.79
|
|
|
Service Code
|
HCPCS 90702
|
| Hospital Charge Code |
158520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$118.40 |
| Max. Negotiated Rate |
$333.67 |
| Rate for Payer: Aetna Commercial |
$302.82
|
| Rate for Payer: Aetna Medicare |
$118.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$118.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$206.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$224.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$136.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$130.24
|
| Rate for Payer: Cash Price |
$222.45
|
| Rate for Payer: Centivo All Commercial |
$182.98
|
| Rate for Payer: Cigna All Commercial |
$309.63
|
| Rate for Payer: CORVEL All Commercial |
$333.67
|
| Rate for Payer: Coventry All Commercial |
$315.73
|
| Rate for Payer: Encore All Commercial |
$330.26
|
| Rate for Payer: Frontpath All Commercial |
$330.08
|
| Rate for Payer: Humana ChoiceCare |
$309.89
|
| Rate for Payer: Humana Medicare |
$182.98
|
| Rate for Payer: Lucent All Commercial |
$182.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$322.91
|
| Rate for Payer: PHCS All Commercial |
$269.09
|
| Rate for Payer: PHP All Commercial |
$272.10
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$139.93
|
| Rate for Payer: Sagamore Health Network All Products |
$276.98
|
| Rate for Payer: Signature Care EPO |
$297.79
|
| Rate for Payer: Signature Care PPO |
$315.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$304.97
|
| Rate for Payer: United Healthcare Commercial |
$282.72
|
| Rate for Payer: United Healthcare Medicare |
$118.40
|
|
|
TETANUS,DIPHTHERIA TOX PED(PF) 5-25 LF UNIT/0.5 ML IM SUSP
|
Facility
IP
|
$358.79
|
|
|
Service Code
|
HCPCS 90702
|
| Hospital Charge Code |
158520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$269.09 |
| Max. Negotiated Rate |
$333.67 |
| Rate for Payer: Aetna Commercial |
$309.99
|
| Rate for Payer: Cash Price |
$222.45
|
| Rate for Payer: Cigna All Commercial |
$309.63
|
| Rate for Payer: CORVEL All Commercial |
$333.67
|
| Rate for Payer: Coventry All Commercial |
$315.73
|
| Rate for Payer: Encore All Commercial |
$330.26
|
| Rate for Payer: Frontpath All Commercial |
$330.08
|
| Rate for Payer: Humana ChoiceCare |
$309.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$322.91
|
| Rate for Payer: PHCS All Commercial |
$269.09
|
| Rate for Payer: PHP All Commercial |
$272.10
|
| Rate for Payer: Sagamore Health Network All Products |
$276.98
|
| Rate for Payer: Signature Care EPO |
$297.79
|
| Rate for Payer: Signature Care PPO |
$315.73
|
| Rate for Payer: United Healthcare Commercial |
$282.72
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNITS/ML IM SYRG
|
Facility
OP
|
$1,179.18
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
119764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$389.13 |
| Max. Negotiated Rate |
$1,096.64 |
| Rate for Payer: Aetna Commercial |
$995.23
|
| Rate for Payer: Aetna Medicare |
$389.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$389.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$677.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$737.10
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$661.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$447.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$428.04
|
| Rate for Payer: Cash Price |
$731.09
|
| Rate for Payer: Cash Price |
$731.09
|
| Rate for Payer: Centivo All Commercial |
$601.38
|
| Rate for Payer: Cigna All Commercial |
$1,017.63
|
| Rate for Payer: CORVEL All Commercial |
$1,096.64
|
| Rate for Payer: Coventry All Commercial |
$1,037.68
|
| Rate for Payer: Encore All Commercial |
$1,085.43
|
| Rate for Payer: Frontpath All Commercial |
$1,084.84
|
| Rate for Payer: Humana ChoiceCare |
$1,018.46
|
| Rate for Payer: Humana Medicare |
$601.38
|
| Rate for Payer: Lucent All Commercial |
$601.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,061.26
|
| Rate for Payer: Managed Health Services Medicaid |
$661.77
|
| Rate for Payer: MDWise Medicaid |
$661.77
|
| Rate for Payer: PHCS All Commercial |
$884.38
|
| Rate for Payer: PHP All Commercial |
$894.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$459.88
|
| Rate for Payer: Sagamore Health Network All Products |
$910.33
|
| Rate for Payer: Signature Care EPO |
$978.72
|
| Rate for Payer: Signature Care PPO |
$1,037.68
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,002.30
|
| Rate for Payer: United Healthcare Commercial |
$929.19
|
| Rate for Payer: United Healthcare Medicare |
$389.13
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNITS/ML IM SYRG
|
Facility
IP
|
$1,179.18
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
119764
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$884.38 |
| Max. Negotiated Rate |
$1,096.64 |
| Rate for Payer: Aetna Commercial |
$1,018.81
|
| Rate for Payer: Cash Price |
$731.09
|
| Rate for Payer: Cigna All Commercial |
$1,017.63
|
| Rate for Payer: CORVEL All Commercial |
$1,096.64
|
| Rate for Payer: Coventry All Commercial |
$1,037.68
|
| Rate for Payer: Encore All Commercial |
$1,085.43
|
| Rate for Payer: Frontpath All Commercial |
$1,084.84
|
| Rate for Payer: Humana ChoiceCare |
$1,018.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,061.26
|
| Rate for Payer: PHCS All Commercial |
$884.38
|
| Rate for Payer: PHP All Commercial |
$894.29
|
| Rate for Payer: Sagamore Health Network All Products |
$910.33
|
| Rate for Payer: Signature Care EPO |
$978.72
|
| Rate for Payer: Signature Care PPO |
$1,037.68
|
| Rate for Payer: United Healthcare Commercial |
$929.19
|
|
|
TETRACAINE HCL (PF) 0.5 % OPHT DROP
|
Facility
OP
|
$87.78
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
121651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.97 |
| Max. Negotiated Rate |
$81.64 |
| Rate for Payer: Aetna Commercial |
$74.09
|
| Rate for Payer: Aetna Medicare |
$28.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$28.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$50.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$54.87
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$33.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$31.86
|
| Rate for Payer: Cash Price |
$54.42
|
| Rate for Payer: Cash Price |
$54.42
|
| Rate for Payer: Centivo All Commercial |
$44.77
|
| Rate for Payer: Cigna All Commercial |
$75.75
|
| Rate for Payer: CORVEL All Commercial |
$81.64
|
| Rate for Payer: Coventry All Commercial |
$77.25
|
| Rate for Payer: Encore All Commercial |
$80.80
|
| Rate for Payer: Frontpath All Commercial |
$80.76
|
| Rate for Payer: Humana ChoiceCare |
$75.82
|
| Rate for Payer: Humana Medicare |
$44.77
|
| Rate for Payer: Lucent All Commercial |
$44.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$79.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$65.84
|
| Rate for Payer: PHP All Commercial |
$66.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$34.23
|
| Rate for Payer: Sagamore Health Network All Products |
$67.77
|
| Rate for Payer: Signature Care EPO |
$72.86
|
| Rate for Payer: Signature Care PPO |
$77.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$74.61
|
| Rate for Payer: United Healthcare Commercial |
$69.17
|
| Rate for Payer: United Healthcare Medicare |
$28.97
|
|
|
TETRACAINE HCL (PF) 0.5 % OPHT DROP
|
Facility
IP
|
$87.78
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
121651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.84 |
| Max. Negotiated Rate |
$81.64 |
| Rate for Payer: Aetna Commercial |
$75.84
|
| Rate for Payer: Cash Price |
$54.42
|
| Rate for Payer: Cigna All Commercial |
$75.75
|
| Rate for Payer: CORVEL All Commercial |
$81.64
|
| Rate for Payer: Coventry All Commercial |
$77.25
|
| Rate for Payer: Encore All Commercial |
$80.80
|
| Rate for Payer: Frontpath All Commercial |
$80.76
|
| Rate for Payer: Humana ChoiceCare |
$75.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$79.00
|
| Rate for Payer: PHCS All Commercial |
$65.84
|
| Rate for Payer: PHP All Commercial |
$66.57
|
| Rate for Payer: Sagamore Health Network All Products |
$67.77
|
| Rate for Payer: Signature Care EPO |
$72.86
|
| Rate for Payer: Signature Care PPO |
$77.25
|
| Rate for Payer: United Healthcare Commercial |
$69.17
|
|
|
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBQ SYRG
|
Facility
IP
|
$14,563.19
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
196782
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10,922.39 |
| Max. Negotiated Rate |
$13,543.76 |
| Rate for Payer: Aetna Commercial |
$12,582.59
|
| Rate for Payer: Cash Price |
$9,029.18
|
| Rate for Payer: Cigna All Commercial |
$12,568.03
|
| Rate for Payer: CORVEL All Commercial |
$13,543.76
|
| Rate for Payer: Coventry All Commercial |
$12,815.60
|
| Rate for Payer: Encore All Commercial |
$13,405.41
|
| Rate for Payer: Frontpath All Commercial |
$13,398.13
|
| Rate for Payer: Humana ChoiceCare |
$12,578.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13,106.87
|
| Rate for Payer: PHCS All Commercial |
$10,922.39
|
| Rate for Payer: PHP All Commercial |
$11,044.72
|
| Rate for Payer: Sagamore Health Network All Products |
$11,242.78
|
| Rate for Payer: Signature Care EPO |
$12,087.44
|
| Rate for Payer: Signature Care PPO |
$12,815.60
|
| Rate for Payer: United Healthcare Commercial |
$11,475.79
|
|
|
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBQ SYRG
|
Facility
OP
|
$14,563.19
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
196782
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.23 |
| Max. Negotiated Rate |
$13,543.76 |
| Rate for Payer: Aetna Commercial |
$12,291.33
|
| Rate for Payer: Aetna Medicare |
$4,805.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4,805.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8,363.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9,103.45
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$19.23
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5,526.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5,286.44
|
| Rate for Payer: Cash Price |
$9,029.18
|
| Rate for Payer: Cash Price |
$9,029.18
|
| Rate for Payer: Centivo All Commercial |
$7,427.22
|
| Rate for Payer: Cigna All Commercial |
$12,568.03
|
| Rate for Payer: CORVEL All Commercial |
$13,543.76
|
| Rate for Payer: Coventry All Commercial |
$12,815.60
|
| Rate for Payer: Encore All Commercial |
$13,405.41
|
| Rate for Payer: Frontpath All Commercial |
$13,398.13
|
| Rate for Payer: Humana ChoiceCare |
$12,578.22
|
| Rate for Payer: Humana Medicare |
$7,427.22
|
| Rate for Payer: Lucent All Commercial |
$7,427.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13,106.87
|
| Rate for Payer: Managed Health Services Medicaid |
$19.23
|
| Rate for Payer: MDWise Medicaid |
$19.23
|
| Rate for Payer: PHCS All Commercial |
$10,922.39
|
| Rate for Payer: PHP All Commercial |
$11,044.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5,679.64
|
| Rate for Payer: Sagamore Health Network All Products |
$11,242.78
|
| Rate for Payer: Signature Care EPO |
$12,087.44
|
| Rate for Payer: Signature Care PPO |
$12,815.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12,378.71
|
| Rate for Payer: United Healthcare Commercial |
$11,475.79
|
| Rate for Payer: United Healthcare Medicare |
$4,805.85
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJ SOLN
|
Facility
OP
|
$22.04
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
7876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.27 |
| Max. Negotiated Rate |
$20.49 |
| Rate for Payer: Aetna Commercial |
$18.60
|
| Rate for Payer: Aetna Medicare |
$7.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.27
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$12.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.00
|
| Rate for Payer: Cash Price |
$13.66
|
| Rate for Payer: Centivo All Commercial |
$11.24
|
| Rate for Payer: Cigna All Commercial |
$19.02
|
| Rate for Payer: CORVEL All Commercial |
$20.49
|
| Rate for Payer: Coventry All Commercial |
$19.39
|
| Rate for Payer: Encore All Commercial |
$20.28
|
| Rate for Payer: Frontpath All Commercial |
$20.27
|
| Rate for Payer: Humana ChoiceCare |
$19.03
|
| Rate for Payer: Humana Medicare |
$11.24
|
| Rate for Payer: Lucent All Commercial |
$11.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.83
|
| Rate for Payer: PHCS All Commercial |
$16.53
|
| Rate for Payer: PHP All Commercial |
$16.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.59
|
| Rate for Payer: Sagamore Health Network All Products |
$17.01
|
| Rate for Payer: Signature Care EPO |
$18.29
|
| Rate for Payer: Signature Care PPO |
$19.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.73
|
| Rate for Payer: United Healthcare Commercial |
$17.36
|
| Rate for Payer: United Healthcare Medicare |
$7.27
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJ SOLN
|
Facility
IP
|
$22.04
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
7876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.53 |
| Max. Negotiated Rate |
$20.49 |
| Rate for Payer: Aetna Commercial |
$19.04
|
| Rate for Payer: Cash Price |
$13.66
|
| Rate for Payer: Cigna All Commercial |
$19.02
|
| Rate for Payer: CORVEL All Commercial |
$20.49
|
| Rate for Payer: Coventry All Commercial |
$19.39
|
| Rate for Payer: Encore All Commercial |
$20.28
|
| Rate for Payer: Frontpath All Commercial |
$20.27
|
| Rate for Payer: Humana ChoiceCare |
$19.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.83
|
| Rate for Payer: PHCS All Commercial |
$16.53
|
| Rate for Payer: PHP All Commercial |
$16.71
|
| Rate for Payer: Sagamore Health Network All Products |
$17.01
|
| Rate for Payer: Signature Care EPO |
$18.29
|
| Rate for Payer: Signature Care PPO |
$19.39
|
| Rate for Payer: United Healthcare Commercial |
$17.36
|
|
|
THIAMINE MONONITRATE (VIT B1) 100 MG ORAL TAB
|
Facility
IP
|
$0.97
|
|
|
Service Code
|
NDC 77333093410
|
| Hospital Charge Code |
121375
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna Commercial |
$0.83
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.83
|
| Rate for Payer: CORVEL All Commercial |
$0.90
|
| Rate for Payer: Coventry All Commercial |
$0.85
|
| Rate for Payer: Encore All Commercial |
$0.89
|
| Rate for Payer: Frontpath All Commercial |
$0.89
|
| Rate for Payer: Humana ChoiceCare |
$0.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.87
|
| Rate for Payer: PHCS All Commercial |
$0.72
|
| Rate for Payer: PHP All Commercial |
$0.73
|
| Rate for Payer: Sagamore Health Network All Products |
$0.75
|
| Rate for Payer: Signature Care EPO |
$0.80
|
| Rate for Payer: Signature Care PPO |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.76
|
|
|
THIAMINE MONONITRATE (VIT B1) 100 MG ORAL TAB
|
Facility
OP
|
$0.97
|
|
|
Service Code
|
NDC 77333093410
|
| Hospital Charge Code |
121375
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna Commercial |
$0.82
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.60
|
| 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 |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.49
|
| Rate for Payer: Cigna All Commercial |
$0.83
|
| Rate for Payer: CORVEL All Commercial |
$0.90
|
| Rate for Payer: Coventry All Commercial |
$0.85
|
| Rate for Payer: Encore All Commercial |
$0.89
|
| Rate for Payer: Frontpath All Commercial |
$0.89
|
| Rate for Payer: Humana ChoiceCare |
$0.83
|
| Rate for Payer: Humana Medicare |
$0.49
|
| Rate for Payer: Lucent All Commercial |
$0.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.87
|
| Rate for Payer: PHCS All Commercial |
$0.72
|
| Rate for Payer: PHP All Commercial |
$0.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.38
|
| Rate for Payer: Sagamore Health Network All Products |
$0.75
|
| Rate for Payer: Signature Care EPO |
$0.80
|
| Rate for Payer: Signature Care PPO |
$0.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$0.76
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance
|
Facility
OP
|
$1,283.57
|
|
|
Service Code
|
CPT 32555
|
| Hospital Charge Code |
CPT-32555
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,283.57 |
| Max. Negotiated Rate |
$1,283.57 |
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$1,283.57
|
| Rate for Payer: Managed Health Services Medicaid |
$1,283.57
|
| Rate for Payer: MDWise Medicaid |
$1,283.57
|
|
|
THROMBIN (BOVINE) 5000 UNITS TOP SOLR
|
Facility
OP
|
$309.75
|
|
|
Service Code
|
NDC 60793021505
|
| Hospital Charge Code |
119314
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$288.07 |
| Rate for Payer: Aetna Commercial |
$261.43
|
| Rate for Payer: Aetna Medicare |
$102.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$102.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$177.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$193.62
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$117.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$112.44
|
| Rate for Payer: Cash Price |
$192.05
|
| Rate for Payer: Cash Price |
$192.05
|
| Rate for Payer: Centivo All Commercial |
$157.97
|
| Rate for Payer: Cigna All Commercial |
$267.31
|
| Rate for Payer: CORVEL All Commercial |
$288.07
|
| Rate for Payer: Coventry All Commercial |
$272.58
|
| Rate for Payer: Encore All Commercial |
$285.12
|
| Rate for Payer: Frontpath All Commercial |
$284.97
|
| Rate for Payer: Humana ChoiceCare |
$267.53
|
| Rate for Payer: Humana Medicare |
$157.97
|
| Rate for Payer: Lucent All Commercial |
$157.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$278.78
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$232.31
|
| Rate for Payer: PHP All Commercial |
$234.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$120.80
|
| Rate for Payer: Sagamore Health Network All Products |
$239.13
|
| Rate for Payer: Signature Care EPO |
$257.09
|
| Rate for Payer: Signature Care PPO |
$272.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$263.29
|
| Rate for Payer: United Healthcare Commercial |
$244.08
|
| Rate for Payer: United Healthcare Medicare |
$102.22
|
|
|
THROMBIN (BOVINE) 5000 UNITS TOP SOLR
|
Facility
IP
|
$309.75
|
|
|
Service Code
|
NDC 60793021505
|
| Hospital Charge Code |
119314
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$232.31 |
| Max. Negotiated Rate |
$288.07 |
| Rate for Payer: Aetna Commercial |
$267.62
|
| Rate for Payer: Cash Price |
$192.05
|
| Rate for Payer: Cigna All Commercial |
$267.31
|
| Rate for Payer: CORVEL All Commercial |
$288.07
|
| Rate for Payer: Coventry All Commercial |
$272.58
|
| Rate for Payer: Encore All Commercial |
$285.12
|
| Rate for Payer: Frontpath All Commercial |
$284.97
|
| Rate for Payer: Humana ChoiceCare |
$267.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$278.78
|
| Rate for Payer: PHCS All Commercial |
$232.31
|
| Rate for Payer: PHP All Commercial |
$234.91
|
| Rate for Payer: Sagamore Health Network All Products |
$239.13
|
| Rate for Payer: Signature Care EPO |
$257.09
|
| Rate for Payer: Signature Care PPO |
$272.58
|
| Rate for Payer: United Healthcare Commercial |
$244.08
|
|
|
THROMBIN (RECOMBINANT) 5000 UNITS TOP SOLR
|
Facility
IP
|
$490.20
|
|
|
Service Code
|
NDC 43825060641
|
| Hospital Charge Code |
89570
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$367.65 |
| Max. Negotiated Rate |
$455.89 |
| Rate for Payer: Aetna Commercial |
$423.53
|
| Rate for Payer: Cash Price |
$303.92
|
| Rate for Payer: Cigna All Commercial |
$423.04
|
| Rate for Payer: CORVEL All Commercial |
$455.89
|
| Rate for Payer: Coventry All Commercial |
$431.38
|
| Rate for Payer: Encore All Commercial |
$451.23
|
| Rate for Payer: Frontpath All Commercial |
$450.98
|
| Rate for Payer: Humana ChoiceCare |
$423.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$441.18
|
| Rate for Payer: PHCS All Commercial |
$367.65
|
| Rate for Payer: PHP All Commercial |
$371.77
|
| Rate for Payer: Sagamore Health Network All Products |
$378.43
|
| Rate for Payer: Signature Care EPO |
$406.87
|
| Rate for Payer: Signature Care PPO |
$431.38
|
| Rate for Payer: United Healthcare Commercial |
$386.28
|
|
|
THROMBIN (RECOMBINANT) 5000 UNITS TOP SOLR
|
Facility
OP
|
$490.20
|
|
|
Service Code
|
NDC 43825060641
|
| Hospital Charge Code |
89570
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$455.89 |
| Rate for Payer: Aetna Commercial |
$413.73
|
| Rate for Payer: Aetna Medicare |
$161.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$161.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$281.52
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$306.42
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$186.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$177.94
|
| Rate for Payer: Cash Price |
$303.92
|
| Rate for Payer: Cash Price |
$303.92
|
| Rate for Payer: Centivo All Commercial |
$250.00
|
| Rate for Payer: Cigna All Commercial |
$423.04
|
| Rate for Payer: CORVEL All Commercial |
$455.89
|
| Rate for Payer: Coventry All Commercial |
$431.38
|
| Rate for Payer: Encore All Commercial |
$451.23
|
| Rate for Payer: Frontpath All Commercial |
$450.98
|
| Rate for Payer: Humana ChoiceCare |
$423.39
|
| Rate for Payer: Humana Medicare |
$250.00
|
| Rate for Payer: Lucent All Commercial |
$250.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$441.18
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$367.65
|
| Rate for Payer: PHP All Commercial |
$371.77
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$191.18
|
| Rate for Payer: Sagamore Health Network All Products |
$378.43
|
| Rate for Payer: Signature Care EPO |
$406.87
|
| Rate for Payer: Signature Care PPO |
$431.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$416.67
|
| Rate for Payer: United Healthcare Commercial |
$386.28
|
| Rate for Payer: United Healthcare Medicare |
$161.77
|
|
|
TICAGRELOR 90 MG ORAL TAB
|
Facility
OP
|
$49.68
|
|
|
Service Code
|
NDC 00186077760
|
| Hospital Charge Code |
152687
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.39 |
| Max. Negotiated Rate |
$46.20 |
| Rate for Payer: Aetna Commercial |
$41.93
|
| Rate for Payer: Aetna Medicare |
$16.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$28.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.03
|
| Rate for Payer: Cash Price |
$30.80
|
| Rate for Payer: Centivo All Commercial |
$25.34
|
| Rate for Payer: Cigna All Commercial |
$42.87
|
| Rate for Payer: CORVEL All Commercial |
$46.20
|
| Rate for Payer: Coventry All Commercial |
$43.72
|
| Rate for Payer: Encore All Commercial |
$45.73
|
| Rate for Payer: Frontpath All Commercial |
$45.70
|
| Rate for Payer: Humana ChoiceCare |
$42.91
|
| Rate for Payer: Humana Medicare |
$25.34
|
| Rate for Payer: Lucent All Commercial |
$25.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.71
|
| Rate for Payer: PHCS All Commercial |
$37.26
|
| Rate for Payer: PHP All Commercial |
$37.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.37
|
| Rate for Payer: Sagamore Health Network All Products |
$38.35
|
| Rate for Payer: Signature Care EPO |
$41.23
|
| Rate for Payer: Signature Care PPO |
$43.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$42.23
|
| Rate for Payer: United Healthcare Commercial |
$39.15
|
| Rate for Payer: United Healthcare Medicare |
$16.39
|
|
