|
TICAGRELOR 90 MG ORAL TAB
|
Facility
IP
|
$49.68
|
|
|
Service Code
|
NDC 00186077760
|
| Hospital Charge Code |
152687
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.26 |
| Max. Negotiated Rate |
$46.20 |
| Rate for Payer: Aetna Commercial |
$42.92
|
| Rate for Payer: Cash Price |
$30.80
|
| 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: 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: 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: United Healthcare Commercial |
$39.15
|
|
|
TILDRAKIZUMAB-ASMN 100 MG/ML SUBQ SYRG
|
Facility
OP
|
$63,347.69
|
|
|
Service Code
|
HCPCS J3245
|
| Hospital Charge Code |
185525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$172.37 |
| Max. Negotiated Rate |
$58,913.35 |
| Rate for Payer: Aetna Commercial |
$53,465.45
|
| Rate for Payer: Aetna Medicare |
$20,904.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$20,904.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$36,380.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39,598.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$172.37
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$24,040.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22,995.21
|
| Rate for Payer: Cash Price |
$39,275.57
|
| Rate for Payer: Cash Price |
$39,275.57
|
| Rate for Payer: Centivo All Commercial |
$32,307.32
|
| Rate for Payer: Cigna All Commercial |
$54,669.06
|
| Rate for Payer: CORVEL All Commercial |
$58,913.35
|
| Rate for Payer: Coventry All Commercial |
$55,745.97
|
| Rate for Payer: Encore All Commercial |
$58,311.55
|
| Rate for Payer: Frontpath All Commercial |
$58,279.87
|
| Rate for Payer: Humana ChoiceCare |
$54,713.40
|
| Rate for Payer: Humana Medicare |
$32,307.32
|
| Rate for Payer: Lucent All Commercial |
$32,307.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$57,012.92
|
| Rate for Payer: Managed Health Services Medicaid |
$172.37
|
| Rate for Payer: MDWise Medicaid |
$172.37
|
| Rate for Payer: PHCS All Commercial |
$47,510.77
|
| Rate for Payer: PHP All Commercial |
$48,042.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24,705.60
|
| Rate for Payer: Sagamore Health Network All Products |
$48,904.42
|
| Rate for Payer: Signature Care EPO |
$52,578.58
|
| Rate for Payer: Signature Care PPO |
$55,745.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$53,845.54
|
| Rate for Payer: United Healthcare Commercial |
$49,917.98
|
| Rate for Payer: United Healthcare Medicare |
$20,904.74
|
|
|
TILDRAKIZUMAB-ASMN 100 MG/ML SUBQ SYRG
|
Facility
IP
|
$63,347.69
|
|
|
Service Code
|
HCPCS J3245
|
| Hospital Charge Code |
185525
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47,510.77 |
| Max. Negotiated Rate |
$58,913.35 |
| Rate for Payer: Aetna Commercial |
$54,732.40
|
| Rate for Payer: Cash Price |
$39,275.57
|
| Rate for Payer: Cigna All Commercial |
$54,669.06
|
| Rate for Payer: CORVEL All Commercial |
$58,913.35
|
| Rate for Payer: Coventry All Commercial |
$55,745.97
|
| Rate for Payer: Encore All Commercial |
$58,311.55
|
| Rate for Payer: Frontpath All Commercial |
$58,279.87
|
| Rate for Payer: Humana ChoiceCare |
$54,713.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$57,012.92
|
| Rate for Payer: PHCS All Commercial |
$47,510.77
|
| Rate for Payer: PHP All Commercial |
$48,042.89
|
| Rate for Payer: Sagamore Health Network All Products |
$48,904.42
|
| Rate for Payer: Signature Care EPO |
$52,578.58
|
| Rate for Payer: Signature Care PPO |
$55,745.97
|
| Rate for Payer: United Healthcare Commercial |
$49,917.98
|
|
|
TIMOLOL MALEATE 0.25 % OPHT DROP
|
Facility
OP
|
$15.75
|
|
|
Service Code
|
NDC 61314022605
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$14.65 |
| Rate for Payer: Aetna Commercial |
$13.29
|
| Rate for Payer: Aetna Medicare |
$5.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$9.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.72
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Centivo All Commercial |
$8.03
|
| Rate for Payer: Cigna All Commercial |
$13.59
|
| Rate for Payer: CORVEL All Commercial |
$14.65
|
| Rate for Payer: Coventry All Commercial |
$13.86
|
| Rate for Payer: Encore All Commercial |
$14.50
|
| Rate for Payer: Frontpath All Commercial |
$14.49
|
| Rate for Payer: Humana ChoiceCare |
$13.60
|
| Rate for Payer: Humana Medicare |
$8.03
|
| Rate for Payer: Lucent All Commercial |
$8.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.18
|
| Rate for Payer: PHCS All Commercial |
$11.81
|
| Rate for Payer: PHP All Commercial |
$11.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.14
|
| Rate for Payer: Sagamore Health Network All Products |
$12.16
|
| Rate for Payer: Signature Care EPO |
$13.07
|
| Rate for Payer: Signature Care PPO |
$13.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13.39
|
| Rate for Payer: United Healthcare Commercial |
$12.41
|
| Rate for Payer: United Healthcare Medicare |
$5.20
|
|
|
TIMOLOL MALEATE 0.25 % OPHT DROP
|
Facility
IP
|
$15.75
|
|
|
Service Code
|
NDC 61314022605
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.81 |
| Max. Negotiated Rate |
$14.65 |
| Rate for Payer: Aetna Commercial |
$13.61
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Cigna All Commercial |
$13.59
|
| Rate for Payer: CORVEL All Commercial |
$14.65
|
| Rate for Payer: Coventry All Commercial |
$13.86
|
| Rate for Payer: Encore All Commercial |
$14.50
|
| Rate for Payer: Frontpath All Commercial |
$14.49
|
| Rate for Payer: Humana ChoiceCare |
$13.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.18
|
| Rate for Payer: PHCS All Commercial |
$11.81
|
| Rate for Payer: PHP All Commercial |
$11.94
|
| Rate for Payer: Sagamore Health Network All Products |
$12.16
|
| Rate for Payer: Signature Care EPO |
$13.07
|
| Rate for Payer: Signature Care PPO |
$13.86
|
| Rate for Payer: United Healthcare Commercial |
$12.41
|
|
|
TIMOLOL MALEATE 0.5 % OPHT DROP
|
Facility
OP
|
$31.29
|
|
|
Service Code
|
NDC 61314022705
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.33 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$26.41
|
| Rate for Payer: Aetna Medicare |
$10.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$17.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.36
|
| Rate for Payer: Cash Price |
$19.40
|
| Rate for Payer: Cash Price |
$19.40
|
| Rate for Payer: Centivo All Commercial |
$15.96
|
| Rate for Payer: Cigna All Commercial |
$27.00
|
| Rate for Payer: CORVEL All Commercial |
$29.10
|
| Rate for Payer: Coventry All Commercial |
$27.54
|
| Rate for Payer: Encore All Commercial |
$28.80
|
| Rate for Payer: Frontpath All Commercial |
$28.79
|
| Rate for Payer: Humana ChoiceCare |
$27.03
|
| Rate for Payer: Humana Medicare |
$15.96
|
| Rate for Payer: Lucent All Commercial |
$15.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.16
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$23.47
|
| Rate for Payer: PHP All Commercial |
$23.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.20
|
| Rate for Payer: Sagamore Health Network All Products |
$24.16
|
| Rate for Payer: Signature Care EPO |
$25.97
|
| Rate for Payer: Signature Care PPO |
$27.54
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$26.60
|
| Rate for Payer: United Healthcare Commercial |
$24.66
|
| Rate for Payer: United Healthcare Medicare |
$10.33
|
|
|
TIMOLOL MALEATE 0.5 % OPHT DROP
|
Facility
IP
|
$31.29
|
|
|
Service Code
|
NDC 61314022705
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.47 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Aetna Commercial |
$27.03
|
| Rate for Payer: Cash Price |
$19.40
|
| Rate for Payer: Cigna All Commercial |
$27.00
|
| Rate for Payer: CORVEL All Commercial |
$29.10
|
| Rate for Payer: Coventry All Commercial |
$27.54
|
| Rate for Payer: Encore All Commercial |
$28.80
|
| Rate for Payer: Frontpath All Commercial |
$28.79
|
| Rate for Payer: Humana ChoiceCare |
$27.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.16
|
| Rate for Payer: PHCS All Commercial |
$23.47
|
| Rate for Payer: PHP All Commercial |
$23.73
|
| Rate for Payer: Sagamore Health Network All Products |
$24.16
|
| Rate for Payer: Signature Care EPO |
$25.97
|
| Rate for Payer: Signature Care PPO |
$27.54
|
| Rate for Payer: United Healthcare Commercial |
$24.66
|
|
|
TIOTROPIUM-OLODATEROL 2.5-2.5 MCG/ACTUATION INHL MIST
|
Facility
IP
|
$1,284.56
|
|
|
Service Code
|
NDC 00597015561
|
| Hospital Charge Code |
172695
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$963.42 |
| Max. Negotiated Rate |
$1,194.64 |
| Rate for Payer: Aetna Commercial |
$1,109.86
|
| Rate for Payer: Cash Price |
$796.43
|
| Rate for Payer: Cigna All Commercial |
$1,108.58
|
| Rate for Payer: CORVEL All Commercial |
$1,194.64
|
| Rate for Payer: Coventry All Commercial |
$1,130.41
|
| Rate for Payer: Encore All Commercial |
$1,182.44
|
| Rate for Payer: Frontpath All Commercial |
$1,181.80
|
| Rate for Payer: Humana ChoiceCare |
$1,109.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,156.10
|
| Rate for Payer: PHCS All Commercial |
$963.42
|
| Rate for Payer: PHP All Commercial |
$974.21
|
| Rate for Payer: Sagamore Health Network All Products |
$991.68
|
| Rate for Payer: Signature Care EPO |
$1,066.18
|
| Rate for Payer: Signature Care PPO |
$1,130.41
|
| Rate for Payer: United Healthcare Commercial |
$1,012.23
|
|
|
TIOTROPIUM-OLODATEROL 2.5-2.5 MCG/ACTUATION INHL MIST
|
Facility
OP
|
$1,284.56
|
|
|
Service Code
|
NDC 00597015561
|
| Hospital Charge Code |
172695
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$1,194.64 |
| Rate for Payer: Aetna Commercial |
$1,084.17
|
| Rate for Payer: Aetna Medicare |
$423.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$423.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$737.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$802.98
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$487.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$466.30
|
| Rate for Payer: Cash Price |
$796.43
|
| Rate for Payer: Cash Price |
$796.43
|
| Rate for Payer: Centivo All Commercial |
$655.13
|
| Rate for Payer: Cigna All Commercial |
$1,108.58
|
| Rate for Payer: CORVEL All Commercial |
$1,194.64
|
| Rate for Payer: Coventry All Commercial |
$1,130.41
|
| Rate for Payer: Encore All Commercial |
$1,182.44
|
| Rate for Payer: Frontpath All Commercial |
$1,181.80
|
| Rate for Payer: Humana ChoiceCare |
$1,109.47
|
| Rate for Payer: Humana Medicare |
$655.13
|
| Rate for Payer: Lucent All Commercial |
$655.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,156.10
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$963.42
|
| Rate for Payer: PHP All Commercial |
$974.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$500.98
|
| Rate for Payer: Sagamore Health Network All Products |
$991.68
|
| Rate for Payer: Signature Care EPO |
$1,066.18
|
| Rate for Payer: Signature Care PPO |
$1,130.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,091.88
|
| Rate for Payer: United Healthcare Commercial |
$1,012.23
|
| Rate for Payer: United Healthcare Medicare |
$423.90
|
|
|
TIXAGEVIMAB-CILGAVIMAB 150 MG/1.5 ML- 150 MG/1.5 ML IM SOLN
|
Facility
IP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0221
|
| Hospital Charge Code |
196738
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
TIXAGEVIMAB-CILGAVIMAB 150 MG/1.5 ML- 150 MG/1.5 ML IM SOLN
|
Facility
OP
|
$0.01
|
|
|
Service Code
|
HCPCS Q0221
|
| Hospital Charge Code |
196738
|
|
Hospital Revenue Code
|
636
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Centivo All Commercial |
$0.01
|
| Rate for Payer: Cigna All Commercial |
$0.01
|
| Rate for Payer: CORVEL All Commercial |
$0.01
|
| Rate for Payer: Coventry All Commercial |
$0.01
|
| Rate for Payer: Encore All Commercial |
$0.01
|
| Rate for Payer: Frontpath All Commercial |
$0.01
|
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: Humana Medicare |
$0.01
|
| Rate for Payer: Lucent All Commercial |
$0.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.01
|
| Rate for Payer: PHCS All Commercial |
$0.01
|
| Rate for Payer: PHP All Commercial |
$0.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.00
|
| Rate for Payer: Sagamore Health Network All Products |
$0.01
|
| Rate for Payer: Signature Care EPO |
$0.01
|
| Rate for Payer: Signature Care PPO |
$0.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
|
|
TIZANIDINE 4 MG ORAL TAB
|
Facility
OP
|
$2.51
|
|
|
Service Code
|
NDC 00904641861
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna Commercial |
$2.12
|
| Rate for Payer: Aetna Medicare |
$0.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.91
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Centivo All Commercial |
$1.28
|
| Rate for Payer: Cigna All Commercial |
$2.17
|
| Rate for Payer: CORVEL All Commercial |
$2.34
|
| Rate for Payer: Coventry All Commercial |
$2.21
|
| Rate for Payer: Encore All Commercial |
$2.31
|
| Rate for Payer: Frontpath All Commercial |
$2.31
|
| Rate for Payer: Humana ChoiceCare |
$2.17
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$1.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.26
|
| Rate for Payer: PHCS All Commercial |
$1.88
|
| Rate for Payer: PHP All Commercial |
$1.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.98
|
| Rate for Payer: Sagamore Health Network All Products |
$1.94
|
| Rate for Payer: Signature Care EPO |
$2.09
|
| Rate for Payer: Signature Care PPO |
$2.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.14
|
| Rate for Payer: United Healthcare Commercial |
$1.98
|
| Rate for Payer: United Healthcare Medicare |
$0.83
|
|
|
TIZANIDINE 4 MG ORAL TAB
|
Facility
IP
|
$2.51
|
|
|
Service Code
|
NDC 00904641861
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna Commercial |
$2.17
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Cigna All Commercial |
$2.17
|
| Rate for Payer: CORVEL All Commercial |
$2.34
|
| Rate for Payer: Coventry All Commercial |
$2.21
|
| Rate for Payer: Encore All Commercial |
$2.31
|
| Rate for Payer: Frontpath All Commercial |
$2.31
|
| Rate for Payer: Humana ChoiceCare |
$2.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.26
|
| Rate for Payer: PHCS All Commercial |
$1.88
|
| Rate for Payer: PHP All Commercial |
$1.91
|
| Rate for Payer: Sagamore Health Network All Products |
$1.94
|
| Rate for Payer: Signature Care EPO |
$2.09
|
| Rate for Payer: Signature Care PPO |
$2.21
|
| Rate for Payer: United Healthcare Commercial |
$1.98
|
|
|
TOBRAMYCIN 0.3 % OPHT DROP
|
Facility
OP
|
$19.22
|
|
|
Service Code
|
NDC 62332051805
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$16.22
|
| Rate for Payer: Aetna Medicare |
$6.34
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.01
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.98
|
| Rate for Payer: Cash Price |
$11.91
|
| Rate for Payer: Cash Price |
$11.91
|
| Rate for Payer: Centivo All Commercial |
$9.80
|
| Rate for Payer: Cigna All Commercial |
$16.58
|
| Rate for Payer: CORVEL All Commercial |
$17.87
|
| Rate for Payer: Coventry All Commercial |
$16.91
|
| Rate for Payer: Encore All Commercial |
$17.69
|
| Rate for Payer: Frontpath All Commercial |
$17.68
|
| Rate for Payer: Humana ChoiceCare |
$16.60
|
| Rate for Payer: Humana Medicare |
$9.80
|
| Rate for Payer: Lucent All Commercial |
$9.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.29
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$14.41
|
| Rate for Payer: PHP All Commercial |
$14.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.49
|
| Rate for Payer: Sagamore Health Network All Products |
$14.83
|
| Rate for Payer: Signature Care EPO |
$15.95
|
| Rate for Payer: Signature Care PPO |
$16.91
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.33
|
| Rate for Payer: United Healthcare Commercial |
$15.14
|
| Rate for Payer: United Healthcare Medicare |
$6.34
|
|
|
TOBRAMYCIN 0.3 % OPHT DROP
|
Facility
IP
|
$19.22
|
|
|
Service Code
|
NDC 62332051805
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.41 |
| Max. Negotiated Rate |
$17.87 |
| Rate for Payer: Aetna Commercial |
$16.60
|
| Rate for Payer: Cash Price |
$11.91
|
| Rate for Payer: Cigna All Commercial |
$16.58
|
| Rate for Payer: CORVEL All Commercial |
$17.87
|
| Rate for Payer: Coventry All Commercial |
$16.91
|
| Rate for Payer: Encore All Commercial |
$17.69
|
| Rate for Payer: Frontpath All Commercial |
$17.68
|
| Rate for Payer: Humana ChoiceCare |
$16.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.29
|
| Rate for Payer: PHCS All Commercial |
$14.41
|
| Rate for Payer: PHP All Commercial |
$14.57
|
| Rate for Payer: Sagamore Health Network All Products |
$14.83
|
| Rate for Payer: Signature Care EPO |
$15.95
|
| Rate for Payer: Signature Care PPO |
$16.91
|
| Rate for Payer: United Healthcare Commercial |
$15.14
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT DRPS
|
Facility
IP
|
$381.96
|
|
|
Service Code
|
NDC 00078095325
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$286.47 |
| Max. Negotiated Rate |
$355.23 |
| Rate for Payer: Aetna Commercial |
$330.02
|
| Rate for Payer: Cash Price |
$236.82
|
| Rate for Payer: Cigna All Commercial |
$329.63
|
| Rate for Payer: CORVEL All Commercial |
$355.23
|
| Rate for Payer: Coventry All Commercial |
$336.13
|
| Rate for Payer: Encore All Commercial |
$351.60
|
| Rate for Payer: Frontpath All Commercial |
$351.41
|
| Rate for Payer: Humana ChoiceCare |
$329.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$343.77
|
| Rate for Payer: PHCS All Commercial |
$286.47
|
| Rate for Payer: PHP All Commercial |
$289.68
|
| Rate for Payer: Sagamore Health Network All Products |
$294.88
|
| Rate for Payer: Signature Care EPO |
$317.03
|
| Rate for Payer: Signature Care PPO |
$336.13
|
| Rate for Payer: United Healthcare Commercial |
$300.99
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT DRPS
|
Facility
IP
|
$52.01
|
|
|
Service Code
|
NDC 00574403125
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.01 |
| Max. Negotiated Rate |
$48.37 |
| Rate for Payer: Aetna Commercial |
$44.94
|
| Rate for Payer: Cash Price |
$32.25
|
| Rate for Payer: Cigna All Commercial |
$44.88
|
| Rate for Payer: CORVEL All Commercial |
$48.37
|
| Rate for Payer: Coventry All Commercial |
$45.77
|
| Rate for Payer: Encore All Commercial |
$47.88
|
| Rate for Payer: Frontpath All Commercial |
$47.85
|
| Rate for Payer: Humana ChoiceCare |
$44.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.81
|
| Rate for Payer: PHCS All Commercial |
$39.01
|
| Rate for Payer: PHP All Commercial |
$39.44
|
| Rate for Payer: Sagamore Health Network All Products |
$40.15
|
| Rate for Payer: Signature Care EPO |
$43.17
|
| Rate for Payer: Signature Care PPO |
$45.77
|
| Rate for Payer: United Healthcare Commercial |
$40.98
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT DRPS
|
Facility
OP
|
$52.01
|
|
|
Service Code
|
NDC 00574403125
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$48.37 |
| Rate for Payer: Aetna Commercial |
$43.90
|
| Rate for Payer: Aetna Medicare |
$17.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$29.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$32.51
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$19.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.88
|
| Rate for Payer: Cash Price |
$32.25
|
| Rate for Payer: Cash Price |
$32.25
|
| Rate for Payer: Centivo All Commercial |
$26.53
|
| Rate for Payer: Cigna All Commercial |
$44.88
|
| Rate for Payer: CORVEL All Commercial |
$48.37
|
| Rate for Payer: Coventry All Commercial |
$45.77
|
| Rate for Payer: Encore All Commercial |
$47.88
|
| Rate for Payer: Frontpath All Commercial |
$47.85
|
| Rate for Payer: Humana ChoiceCare |
$44.92
|
| Rate for Payer: Humana Medicare |
$26.53
|
| Rate for Payer: Lucent All Commercial |
$26.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.81
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$39.01
|
| Rate for Payer: PHP All Commercial |
$39.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$20.28
|
| Rate for Payer: Sagamore Health Network All Products |
$40.15
|
| Rate for Payer: Signature Care EPO |
$43.17
|
| Rate for Payer: Signature Care PPO |
$45.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$44.21
|
| Rate for Payer: United Healthcare Commercial |
$40.98
|
| Rate for Payer: United Healthcare Medicare |
$17.16
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT DRPS
|
Facility
OP
|
$381.96
|
|
|
Service Code
|
NDC 00078095325
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$355.23 |
| Rate for Payer: Aetna Commercial |
$322.38
|
| Rate for Payer: Aetna Medicare |
$126.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$126.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$219.36
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$238.77
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$144.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$138.65
|
| Rate for Payer: Cash Price |
$236.82
|
| Rate for Payer: Cash Price |
$236.82
|
| Rate for Payer: Centivo All Commercial |
$194.80
|
| Rate for Payer: Cigna All Commercial |
$329.63
|
| Rate for Payer: CORVEL All Commercial |
$355.23
|
| Rate for Payer: Coventry All Commercial |
$336.13
|
| Rate for Payer: Encore All Commercial |
$351.60
|
| Rate for Payer: Frontpath All Commercial |
$351.41
|
| Rate for Payer: Humana ChoiceCare |
$329.90
|
| Rate for Payer: Humana Medicare |
$194.80
|
| Rate for Payer: Lucent All Commercial |
$194.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$343.77
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$286.47
|
| Rate for Payer: PHP All Commercial |
$289.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$148.97
|
| Rate for Payer: Sagamore Health Network All Products |
$294.88
|
| Rate for Payer: Signature Care EPO |
$317.03
|
| Rate for Payer: Signature Care PPO |
$336.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$324.67
|
| Rate for Payer: United Healthcare Commercial |
$300.99
|
| Rate for Payer: United Healthcare Medicare |
$126.05
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT OINT
|
Facility
IP
|
$546.77
|
|
|
Service Code
|
NDC 00078087601
|
| Hospital Charge Code |
11566
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$410.08 |
| Max. Negotiated Rate |
$508.50 |
| Rate for Payer: Aetna Commercial |
$472.41
|
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Cigna All Commercial |
$471.86
|
| Rate for Payer: CORVEL All Commercial |
$508.50
|
| Rate for Payer: Coventry All Commercial |
$481.16
|
| Rate for Payer: Encore All Commercial |
$503.30
|
| Rate for Payer: Frontpath All Commercial |
$503.03
|
| Rate for Payer: Humana ChoiceCare |
$472.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$492.09
|
| Rate for Payer: PHCS All Commercial |
$410.08
|
| Rate for Payer: PHP All Commercial |
$414.67
|
| Rate for Payer: Sagamore Health Network All Products |
$422.11
|
| Rate for Payer: Signature Care EPO |
$453.82
|
| Rate for Payer: Signature Care PPO |
$481.16
|
| Rate for Payer: United Healthcare Commercial |
$430.85
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT OINT
|
Facility
OP
|
$546.77
|
|
|
Service Code
|
NDC 00078087601
|
| Hospital Charge Code |
11566
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$508.50 |
| Rate for Payer: Aetna Commercial |
$461.47
|
| Rate for Payer: Aetna Medicare |
$180.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$180.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$314.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$341.79
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$207.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$198.48
|
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Centivo All Commercial |
$278.85
|
| Rate for Payer: Cigna All Commercial |
$471.86
|
| Rate for Payer: CORVEL All Commercial |
$508.50
|
| Rate for Payer: Coventry All Commercial |
$481.16
|
| Rate for Payer: Encore All Commercial |
$503.30
|
| Rate for Payer: Frontpath All Commercial |
$503.03
|
| Rate for Payer: Humana ChoiceCare |
$472.25
|
| Rate for Payer: Humana Medicare |
$278.85
|
| Rate for Payer: Lucent All Commercial |
$278.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$492.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$410.08
|
| Rate for Payer: PHP All Commercial |
$414.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$213.24
|
| Rate for Payer: Sagamore Health Network All Products |
$422.11
|
| Rate for Payer: Signature Care EPO |
$453.82
|
| Rate for Payer: Signature Care PPO |
$481.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$464.75
|
| Rate for Payer: United Healthcare Commercial |
$430.85
|
| Rate for Payer: United Healthcare Medicare |
$180.43
|
|
|
TOBRAMYCIN SULFATE 1.2 G INJ SOLR
|
Facility
IP
|
$318.72
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
11565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$239.04 |
| Max. Negotiated Rate |
$296.41 |
| Rate for Payer: Aetna Commercial |
$275.37
|
| Rate for Payer: Cash Price |
$197.61
|
| Rate for Payer: Cigna All Commercial |
$275.06
|
| Rate for Payer: CORVEL All Commercial |
$296.41
|
| Rate for Payer: Coventry All Commercial |
$280.47
|
| Rate for Payer: Encore All Commercial |
$293.38
|
| Rate for Payer: Frontpath All Commercial |
$293.22
|
| Rate for Payer: Humana ChoiceCare |
$275.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$286.85
|
| Rate for Payer: PHCS All Commercial |
$239.04
|
| Rate for Payer: PHP All Commercial |
$241.72
|
| Rate for Payer: Sagamore Health Network All Products |
$246.05
|
| Rate for Payer: Signature Care EPO |
$264.54
|
| Rate for Payer: Signature Care PPO |
$280.47
|
| Rate for Payer: United Healthcare Commercial |
$251.15
|
|
|
TOBRAMYCIN SULFATE 1.2 G INJ SOLR
|
Facility
OP
|
$318.72
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
11565
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.18 |
| Max. Negotiated Rate |
$296.41 |
| Rate for Payer: Aetna Commercial |
$269.00
|
| Rate for Payer: Aetna Medicare |
$105.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$105.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$183.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$199.23
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$120.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$115.70
|
| Rate for Payer: Cash Price |
$197.61
|
| Rate for Payer: Centivo All Commercial |
$162.55
|
| Rate for Payer: Cigna All Commercial |
$275.06
|
| Rate for Payer: CORVEL All Commercial |
$296.41
|
| Rate for Payer: Coventry All Commercial |
$280.47
|
| Rate for Payer: Encore All Commercial |
$293.38
|
| Rate for Payer: Frontpath All Commercial |
$293.22
|
| Rate for Payer: Humana ChoiceCare |
$275.28
|
| Rate for Payer: Humana Medicare |
$162.55
|
| Rate for Payer: Lucent All Commercial |
$162.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$286.85
|
| Rate for Payer: PHCS All Commercial |
$239.04
|
| Rate for Payer: PHP All Commercial |
$241.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$124.30
|
| Rate for Payer: Sagamore Health Network All Products |
$246.05
|
| Rate for Payer: Signature Care EPO |
$264.54
|
| Rate for Payer: Signature Care PPO |
$280.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$270.91
|
| Rate for Payer: United Healthcare Commercial |
$251.15
|
| Rate for Payer: United Healthcare Medicare |
$105.18
|
|
|
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
7994
|
|
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
|
|
|
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
7994
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| 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 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: 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: 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
|
|
