|
TERBUTALINE 2.5 MG ORAL TAB
|
Facility
|
IP
|
$12.30
|
|
|
Service Code
|
NDC 00115261101
|
| Hospital Charge Code |
11508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.22 |
| Max. Negotiated Rate |
$11.44 |
| Rate for Payer: Aetna Commercial |
$10.63
|
| Rate for Payer: Cash Price |
$7.38
|
| Rate for Payer: Cigna All Commercial |
$10.61
|
| Rate for Payer: CORVEL All Commercial |
$11.44
|
| Rate for Payer: Coventry All Commercial |
$10.82
|
| Rate for Payer: Encore All Commercial |
$11.32
|
| Rate for Payer: Frontpath All Commercial |
$11.32
|
| Rate for Payer: Humana ChoiceCare |
$10.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$11.07
|
| Rate for Payer: PHCS All Commercial |
$9.22
|
| Rate for Payer: PHP All Commercial |
$9.33
|
| Rate for Payer: Sagamore Health Network All Products |
$9.49
|
| Rate for Payer: Signature Care EPO |
$10.21
|
| Rate for Payer: Signature Care PPO |
$10.82
|
| Rate for Payer: United Healthcare Commercial |
$9.69
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL
|
Facility
|
IP
|
$88.27
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.20 |
| Max. Negotiated Rate |
$82.09 |
| Rate for Payer: Aetna Commercial |
$76.27
|
| Rate for Payer: Cash Price |
$52.96
|
| Rate for Payer: Cigna All Commercial |
$76.18
|
| Rate for Payer: CORVEL All Commercial |
$82.09
|
| Rate for Payer: Coventry All Commercial |
$77.68
|
| Rate for Payer: Encore All Commercial |
$81.25
|
| Rate for Payer: Frontpath All Commercial |
$81.21
|
| Rate for Payer: Humana ChoiceCare |
$76.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$79.44
|
| Rate for Payer: PHCS All Commercial |
$66.20
|
| Rate for Payer: PHP All Commercial |
$66.94
|
| Rate for Payer: Sagamore Health Network All Products |
$68.14
|
| Rate for Payer: Signature Care EPO |
$73.26
|
| Rate for Payer: Signature Care PPO |
$77.68
|
| Rate for Payer: United Healthcare Commercial |
$69.56
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL
|
Facility
|
OP
|
$88.27
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.36 |
| Max. Negotiated Rate |
$82.09 |
| Rate for Payer: Aetna Commercial |
$74.50
|
| Rate for Payer: Aetna Medicare |
$28.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$27.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$50.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$55.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$32.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$31.07
|
| Rate for Payer: Cash Price |
$52.96
|
| Rate for Payer: Centivo All Commercial |
$48.02
|
| Rate for Payer: Cigna All Commercial |
$76.18
|
| Rate for Payer: CORVEL All Commercial |
$82.09
|
| Rate for Payer: Coventry All Commercial |
$77.68
|
| Rate for Payer: Encore All Commercial |
$81.25
|
| Rate for Payer: Frontpath All Commercial |
$81.21
|
| Rate for Payer: Humana ChoiceCare |
$76.24
|
| Rate for Payer: Humana Medicare |
$28.25
|
| Rate for Payer: Lucent All Commercial |
$48.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$79.44
|
| Rate for Payer: PHCS All Commercial |
$66.20
|
| Rate for Payer: PHP All Commercial |
$66.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$34.43
|
| Rate for Payer: Sagamore Health Network All Products |
$68.14
|
| Rate for Payer: Signature Care EPO |
$73.26
|
| Rate for Payer: Signature Care PPO |
$77.68
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$75.03
|
| Rate for Payer: United Healthcare Commercial |
$69.56
|
| Rate for Payer: United Healthcare Medicare |
$28.25
|
|
|
TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM S.O.
|
Facility
|
OP
|
$265.09
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
420789
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.18 |
| Max. Negotiated Rate |
$246.53 |
| Rate for Payer: Aetna Commercial |
$223.74
|
| Rate for Payer: Aetna Medicare |
$84.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$82.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$152.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$165.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$97.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$93.31
|
| Rate for Payer: Cash Price |
$159.05
|
| Rate for Payer: Centivo All Commercial |
$144.21
|
| Rate for Payer: Cigna All Commercial |
$228.77
|
| Rate for Payer: CORVEL All Commercial |
$246.53
|
| Rate for Payer: Coventry All Commercial |
$233.28
|
| Rate for Payer: Encore All Commercial |
$244.02
|
| Rate for Payer: Frontpath All Commercial |
$243.88
|
| Rate for Payer: Humana ChoiceCare |
$228.96
|
| Rate for Payer: Humana Medicare |
$84.83
|
| Rate for Payer: Lucent All Commercial |
$144.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$238.58
|
| Rate for Payer: PHCS All Commercial |
$198.82
|
| Rate for Payer: PHP All Commercial |
$201.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$103.39
|
| Rate for Payer: Sagamore Health Network All Products |
$204.65
|
| Rate for Payer: Signature Care EPO |
$220.02
|
| Rate for Payer: Signature Care PPO |
$233.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$225.33
|
| Rate for Payer: United Healthcare Commercial |
$208.89
|
| Rate for Payer: United Healthcare Medicare |
$84.83
|
|
|
TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM S.O.
|
Facility
|
IP
|
$265.09
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
420789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$198.82 |
| Max. Negotiated Rate |
$246.53 |
| Rate for Payer: Aetna Commercial |
$229.04
|
| Rate for Payer: Cash Price |
$159.05
|
| Rate for Payer: Cigna All Commercial |
$228.77
|
| Rate for Payer: CORVEL All Commercial |
$246.53
|
| Rate for Payer: Coventry All Commercial |
$233.28
|
| Rate for Payer: Encore All Commercial |
$244.02
|
| Rate for Payer: Frontpath All Commercial |
$243.88
|
| Rate for Payer: Humana ChoiceCare |
$228.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$238.58
|
| Rate for Payer: PHCS All Commercial |
$198.82
|
| Rate for Payer: PHP All Commercial |
$201.04
|
| Rate for Payer: Sagamore Health Network All Products |
$204.65
|
| Rate for Payer: Signature Care EPO |
$220.02
|
| Rate for Payer: Signature Care PPO |
$233.28
|
| Rate for Payer: United Healthcare Commercial |
$208.89
|
|
|
TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM SYRG
|
Facility
|
OP
|
$265.09
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
119618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.18 |
| Max. Negotiated Rate |
$246.53 |
| Rate for Payer: Aetna Commercial |
$223.74
|
| Rate for Payer: Aetna Medicare |
$84.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$82.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$152.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$165.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$97.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$93.31
|
| Rate for Payer: Cash Price |
$159.05
|
| Rate for Payer: Centivo All Commercial |
$144.21
|
| Rate for Payer: Cigna All Commercial |
$228.77
|
| Rate for Payer: CORVEL All Commercial |
$246.53
|
| Rate for Payer: Coventry All Commercial |
$233.28
|
| Rate for Payer: Encore All Commercial |
$244.02
|
| Rate for Payer: Frontpath All Commercial |
$243.88
|
| Rate for Payer: Humana ChoiceCare |
$228.96
|
| Rate for Payer: Humana Medicare |
$84.83
|
| Rate for Payer: Lucent All Commercial |
$144.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$238.58
|
| Rate for Payer: PHCS All Commercial |
$198.82
|
| Rate for Payer: PHP All Commercial |
$201.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$103.39
|
| Rate for Payer: Sagamore Health Network All Products |
$204.65
|
| Rate for Payer: Signature Care EPO |
$220.02
|
| Rate for Payer: Signature Care PPO |
$233.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$225.33
|
| Rate for Payer: United Healthcare Commercial |
$208.89
|
| Rate for Payer: United Healthcare Medicare |
$84.83
|
|
|
TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM SYRG
|
Facility
|
IP
|
$265.09
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
119618
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$198.82 |
| Max. Negotiated Rate |
$246.53 |
| Rate for Payer: Aetna Commercial |
$229.04
|
| Rate for Payer: Cash Price |
$159.05
|
| Rate for Payer: Cigna All Commercial |
$228.77
|
| Rate for Payer: CORVEL All Commercial |
$246.53
|
| Rate for Payer: Coventry All Commercial |
$233.28
|
| Rate for Payer: Encore All Commercial |
$244.02
|
| Rate for Payer: Frontpath All Commercial |
$243.88
|
| Rate for Payer: Humana ChoiceCare |
$228.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$238.58
|
| Rate for Payer: PHCS All Commercial |
$198.82
|
| Rate for Payer: PHP All Commercial |
$201.04
|
| Rate for Payer: Sagamore Health Network All Products |
$204.65
|
| Rate for Payer: Signature Care EPO |
$220.02
|
| Rate for Payer: Signature Care PPO |
$233.28
|
| Rate for Payer: United Healthcare Commercial |
$208.89
|
|
|
TETANUS AND DIPHTHER. TOX (PF) 5 LF UNIT- 2 LF UNIT/0.5ML IM SUSP
|
Facility
|
OP
|
$265.09
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
119619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.18 |
| Max. Negotiated Rate |
$246.53 |
| Rate for Payer: Aetna Commercial |
$223.74
|
| Rate for Payer: Aetna Medicare |
$84.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$82.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$152.24
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$165.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$97.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$93.31
|
| Rate for Payer: Cash Price |
$159.05
|
| Rate for Payer: Centivo All Commercial |
$144.21
|
| Rate for Payer: Cigna All Commercial |
$228.77
|
| Rate for Payer: CORVEL All Commercial |
$246.53
|
| Rate for Payer: Coventry All Commercial |
$233.28
|
| Rate for Payer: Encore All Commercial |
$244.02
|
| Rate for Payer: Frontpath All Commercial |
$243.88
|
| Rate for Payer: Humana ChoiceCare |
$228.96
|
| Rate for Payer: Humana Medicare |
$84.83
|
| Rate for Payer: Lucent All Commercial |
$144.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$238.58
|
| Rate for Payer: PHCS All Commercial |
$198.82
|
| Rate for Payer: PHP All Commercial |
$201.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$103.39
|
| Rate for Payer: Sagamore Health Network All Products |
$204.65
|
| Rate for Payer: Signature Care EPO |
$220.02
|
| Rate for Payer: Signature Care PPO |
$233.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$225.33
|
| Rate for Payer: United Healthcare Commercial |
$208.89
|
| Rate for Payer: United Healthcare Medicare |
$84.83
|
|
|
TETANUS AND DIPHTHER. TOX (PF) 5 LF UNIT- 2 LF UNIT/0.5ML IM SUSP
|
Facility
|
IP
|
$265.09
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
119619
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$198.82 |
| Max. Negotiated Rate |
$246.53 |
| Rate for Payer: Aetna Commercial |
$229.04
|
| Rate for Payer: Cash Price |
$159.05
|
| Rate for Payer: Cigna All Commercial |
$228.77
|
| Rate for Payer: CORVEL All Commercial |
$246.53
|
| Rate for Payer: Coventry All Commercial |
$233.28
|
| Rate for Payer: Encore All Commercial |
$244.02
|
| Rate for Payer: Frontpath All Commercial |
$243.88
|
| Rate for Payer: Humana ChoiceCare |
$228.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$238.58
|
| Rate for Payer: PHCS All Commercial |
$198.82
|
| Rate for Payer: PHP All Commercial |
$201.04
|
| Rate for Payer: Sagamore Health Network All Products |
$204.65
|
| Rate for Payer: Signature Care EPO |
$220.02
|
| Rate for Payer: Signature Care PPO |
$233.28
|
| Rate for Payer: United Healthcare Commercial |
$208.89
|
|
|
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 |
$111.22 |
| Max. Negotiated Rate |
$333.67 |
| Rate for Payer: Aetna Commercial |
$302.82
|
| Rate for Payer: Aetna Medicare |
$114.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$111.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$206.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$224.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$132.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$126.29
|
| Rate for Payer: Cash Price |
$215.27
|
| Rate for Payer: Centivo All Commercial |
$195.18
|
| 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 |
$114.81
|
| Rate for Payer: Lucent All Commercial |
$195.18
|
| 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 |
$114.81
|
|
|
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 |
$215.27
|
| 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
|
$1,183.31
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
119764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$366.83 |
| Max. Negotiated Rate |
$1,100.48 |
| Rate for Payer: Aetna Commercial |
$998.72
|
| Rate for Payer: Aetna Medicare |
$378.66
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$681.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$366.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$679.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$739.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$681.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$435.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$416.53
|
| Rate for Payer: Cash Price |
$709.99
|
| Rate for Payer: Cash Price |
$709.99
|
| Rate for Payer: Centivo All Commercial |
$643.72
|
| Rate for Payer: Cigna All Commercial |
$1,021.20
|
| Rate for Payer: CORVEL All Commercial |
$1,100.48
|
| Rate for Payer: Coventry All Commercial |
$1,041.32
|
| Rate for Payer: Encore All Commercial |
$1,089.24
|
| Rate for Payer: Frontpath All Commercial |
$1,088.65
|
| Rate for Payer: Humana ChoiceCare |
$1,022.03
|
| Rate for Payer: Humana Medicare |
$378.66
|
| Rate for Payer: Lucent All Commercial |
$643.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,064.98
|
| Rate for Payer: Managed Health Services Medicaid |
$681.63
|
| Rate for Payer: MDWise Medicaid |
$681.63
|
| Rate for Payer: PHCS All Commercial |
$887.49
|
| Rate for Payer: PHP All Commercial |
$897.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$461.49
|
| Rate for Payer: Sagamore Health Network All Products |
$913.52
|
| Rate for Payer: Signature Care EPO |
$982.15
|
| Rate for Payer: Signature Care PPO |
$1,041.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,005.82
|
| Rate for Payer: United Healthcare Commercial |
$932.45
|
| Rate for Payer: United Healthcare Medicare |
$378.66
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNITS/ML IM SYRG
|
Facility
|
IP
|
$1,183.31
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
119764
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$887.49 |
| Max. Negotiated Rate |
$1,100.48 |
| Rate for Payer: Aetna Commercial |
$1,022.38
|
| Rate for Payer: Cash Price |
$709.99
|
| Rate for Payer: Cigna All Commercial |
$1,021.20
|
| Rate for Payer: CORVEL All Commercial |
$1,100.48
|
| Rate for Payer: Coventry All Commercial |
$1,041.32
|
| Rate for Payer: Encore All Commercial |
$1,089.24
|
| Rate for Payer: Frontpath All Commercial |
$1,088.65
|
| Rate for Payer: Humana ChoiceCare |
$1,022.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,064.98
|
| Rate for Payer: PHCS All Commercial |
$887.49
|
| Rate for Payer: PHP All Commercial |
$897.43
|
| Rate for Payer: Sagamore Health Network All Products |
$913.52
|
| Rate for Payer: Signature Care EPO |
$982.15
|
| Rate for Payer: Signature Care PPO |
$1,041.32
|
| Rate for Payer: United Healthcare Commercial |
$932.45
|
|
|
TETRACAINE HCL (PF) 0.5 % OPHT DROP
|
Facility
|
OP
|
$91.08
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
121651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$84.71 |
| Rate for Payer: Aetna Commercial |
$76.87
|
| Rate for Payer: Aetna Medicare |
$29.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$28.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$52.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$56.94
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$33.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$32.06
|
| Rate for Payer: Cash Price |
$54.65
|
| Rate for Payer: Cash Price |
$54.65
|
| Rate for Payer: Centivo All Commercial |
$49.55
|
| Rate for Payer: Cigna All Commercial |
$78.61
|
| Rate for Payer: CORVEL All Commercial |
$84.71
|
| Rate for Payer: Coventry All Commercial |
$80.15
|
| Rate for Payer: Encore All Commercial |
$83.84
|
| Rate for Payer: Frontpath All Commercial |
$83.80
|
| Rate for Payer: Humana ChoiceCare |
$78.67
|
| Rate for Payer: Humana Medicare |
$29.15
|
| Rate for Payer: Lucent All Commercial |
$49.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$81.98
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$68.31
|
| Rate for Payer: PHP All Commercial |
$69.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$35.52
|
| Rate for Payer: Sagamore Health Network All Products |
$70.32
|
| Rate for Payer: Signature Care EPO |
$75.60
|
| Rate for Payer: Signature Care PPO |
$80.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$77.42
|
| Rate for Payer: United Healthcare Commercial |
$71.77
|
| Rate for Payer: United Healthcare Medicare |
$29.15
|
|
|
TETRACAINE HCL (PF) 0.5 % OPHT DROP
|
Facility
|
IP
|
$91.08
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
121651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.31 |
| Max. Negotiated Rate |
$84.71 |
| Rate for Payer: Aetna Commercial |
$78.70
|
| Rate for Payer: Cash Price |
$54.65
|
| Rate for Payer: Cigna All Commercial |
$78.61
|
| Rate for Payer: CORVEL All Commercial |
$84.71
|
| Rate for Payer: Coventry All Commercial |
$80.15
|
| Rate for Payer: Encore All Commercial |
$83.84
|
| Rate for Payer: Frontpath All Commercial |
$83.80
|
| Rate for Payer: Humana ChoiceCare |
$78.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$81.98
|
| Rate for Payer: PHCS All Commercial |
$68.31
|
| Rate for Payer: PHP All Commercial |
$69.08
|
| Rate for Payer: Sagamore Health Network All Products |
$70.32
|
| Rate for Payer: Signature Care EPO |
$75.60
|
| Rate for Payer: Signature Care PPO |
$80.15
|
| Rate for Payer: United Healthcare Commercial |
$71.77
|
|
|
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBQ SYRG
|
Facility
|
OP
|
$15,291.36
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
196782
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.83 |
| Max. Negotiated Rate |
$14,220.97 |
| Rate for Payer: Aetna Commercial |
$12,905.91
|
| Rate for Payer: Aetna Medicare |
$4,893.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$21.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4,740.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8,781.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9,558.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$21.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5,627.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5,382.56
|
| Rate for Payer: Cash Price |
$9,174.82
|
| Rate for Payer: Cash Price |
$9,174.82
|
| Rate for Payer: Centivo All Commercial |
$8,318.50
|
| Rate for Payer: Cigna All Commercial |
$13,196.45
|
| Rate for Payer: CORVEL All Commercial |
$14,220.97
|
| Rate for Payer: Coventry All Commercial |
$13,456.40
|
| Rate for Payer: Encore All Commercial |
$14,075.70
|
| Rate for Payer: Frontpath All Commercial |
$14,068.05
|
| Rate for Payer: Humana ChoiceCare |
$13,207.15
|
| Rate for Payer: Humana Medicare |
$4,893.24
|
| Rate for Payer: Lucent All Commercial |
$8,318.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13,762.23
|
| Rate for Payer: Managed Health Services Medicaid |
$21.83
|
| Rate for Payer: MDWise Medicaid |
$21.83
|
| Rate for Payer: PHCS All Commercial |
$11,468.52
|
| Rate for Payer: PHP All Commercial |
$11,596.97
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5,963.63
|
| Rate for Payer: Sagamore Health Network All Products |
$11,804.93
|
| Rate for Payer: Signature Care EPO |
$12,691.83
|
| Rate for Payer: Signature Care PPO |
$13,456.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12,997.66
|
| Rate for Payer: United Healthcare Commercial |
$12,049.59
|
| Rate for Payer: United Healthcare Medicare |
$4,893.24
|
|
|
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBQ SYRG
|
Facility
|
IP
|
$15,291.36
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
196782
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11,468.52 |
| Max. Negotiated Rate |
$14,220.97 |
| Rate for Payer: Aetna Commercial |
$13,211.74
|
| Rate for Payer: Cash Price |
$9,174.82
|
| Rate for Payer: Cigna All Commercial |
$13,196.45
|
| Rate for Payer: CORVEL All Commercial |
$14,220.97
|
| Rate for Payer: Coventry All Commercial |
$13,456.40
|
| Rate for Payer: Encore All Commercial |
$14,075.70
|
| Rate for Payer: Frontpath All Commercial |
$14,068.05
|
| Rate for Payer: Humana ChoiceCare |
$13,207.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13,762.23
|
| Rate for Payer: PHCS All Commercial |
$11,468.52
|
| Rate for Payer: PHP All Commercial |
$11,596.97
|
| Rate for Payer: Sagamore Health Network All Products |
$11,804.93
|
| Rate for Payer: Signature Care EPO |
$12,691.83
|
| Rate for Payer: Signature Care PPO |
$13,456.40
|
| Rate for Payer: United Healthcare Commercial |
$12,049.59
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJ SOLN
|
Facility
|
OP
|
$21.77
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
7876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$20.25 |
| Rate for Payer: Aetna Commercial |
$18.37
|
| Rate for Payer: Aetna Medicare |
$6.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$12.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.61
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.66
|
| Rate for Payer: Cash Price |
$13.06
|
| Rate for Payer: Centivo All Commercial |
$11.84
|
| Rate for Payer: Cigna All Commercial |
$18.79
|
| Rate for Payer: CORVEL All Commercial |
$20.25
|
| Rate for Payer: Coventry All Commercial |
$19.16
|
| Rate for Payer: Encore All Commercial |
$20.04
|
| Rate for Payer: Frontpath All Commercial |
$20.03
|
| Rate for Payer: Humana ChoiceCare |
$18.80
|
| Rate for Payer: Humana Medicare |
$6.97
|
| Rate for Payer: Lucent All Commercial |
$11.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.59
|
| Rate for Payer: PHCS All Commercial |
$16.33
|
| Rate for Payer: PHP All Commercial |
$16.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.49
|
| Rate for Payer: Sagamore Health Network All Products |
$16.81
|
| Rate for Payer: Signature Care EPO |
$18.07
|
| Rate for Payer: Signature Care PPO |
$19.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.50
|
| Rate for Payer: United Healthcare Commercial |
$17.15
|
| Rate for Payer: United Healthcare Medicare |
$6.97
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJ SOLN
|
Facility
|
IP
|
$21.77
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
7876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.33 |
| Max. Negotiated Rate |
$20.25 |
| Rate for Payer: Aetna Commercial |
$18.81
|
| Rate for Payer: Cash Price |
$13.06
|
| Rate for Payer: Cigna All Commercial |
$18.79
|
| Rate for Payer: CORVEL All Commercial |
$20.25
|
| Rate for Payer: Coventry All Commercial |
$19.16
|
| Rate for Payer: Encore All Commercial |
$20.04
|
| Rate for Payer: Frontpath All Commercial |
$20.03
|
| Rate for Payer: Humana ChoiceCare |
$18.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.59
|
| Rate for Payer: PHCS All Commercial |
$16.33
|
| Rate for Payer: PHP All Commercial |
$16.51
|
| Rate for Payer: Sagamore Health Network All Products |
$16.81
|
| Rate for Payer: Signature Care EPO |
$18.07
|
| Rate for Payer: Signature Care PPO |
$19.16
|
| Rate for Payer: United Healthcare Commercial |
$17.15
|
|
|
THIAMINE MONONITRATE (VIT B1) 100 MG ORAL TAB
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 77333093410
|
| Hospital Charge Code |
121375
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna Commercial |
$0.97
|
| Rate for Payer: Aetna Medicare |
$0.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.41
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Centivo All Commercial |
$0.63
|
| Rate for Payer: Cigna All Commercial |
$1.00
|
| Rate for Payer: CORVEL All Commercial |
$1.07
|
| Rate for Payer: Coventry All Commercial |
$1.02
|
| Rate for Payer: Encore All Commercial |
$1.06
|
| Rate for Payer: Frontpath All Commercial |
$1.06
|
| Rate for Payer: Humana ChoiceCare |
$1.00
|
| Rate for Payer: Humana Medicare |
$0.37
|
| Rate for Payer: Lucent All Commercial |
$0.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.04
|
| Rate for Payer: PHCS All Commercial |
$0.87
|
| Rate for Payer: PHP All Commercial |
$0.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.45
|
| Rate for Payer: Sagamore Health Network All Products |
$0.89
|
| Rate for Payer: Signature Care EPO |
$0.96
|
| Rate for Payer: Signature Care PPO |
$1.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$0.91
|
| Rate for Payer: United Healthcare Medicare |
$0.37
|
|
|
THIAMINE MONONITRATE (VIT B1) 100 MG ORAL TAB
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 77333093410
|
| Hospital Charge Code |
121375
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna Commercial |
$1.00
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna All Commercial |
$1.00
|
| Rate for Payer: CORVEL All Commercial |
$1.07
|
| Rate for Payer: Coventry All Commercial |
$1.02
|
| Rate for Payer: Encore All Commercial |
$1.06
|
| Rate for Payer: Frontpath All Commercial |
$1.06
|
| Rate for Payer: Humana ChoiceCare |
$1.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.04
|
| Rate for Payer: PHCS All Commercial |
$0.87
|
| Rate for Payer: PHP All Commercial |
$0.88
|
| Rate for Payer: Sagamore Health Network All Products |
$0.89
|
| Rate for Payer: Signature Care EPO |
$0.96
|
| Rate for Payer: Signature Care PPO |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$0.91
|
|
|
THROMBIN (BOVINE) 5000 UNITS TOP SOLR
|
Facility
|
IP
|
$321.72
|
|
|
Service Code
|
NDC 60793021505
|
| Hospital Charge Code |
119314
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$241.29 |
| Max. Negotiated Rate |
$299.20 |
| Rate for Payer: Aetna Commercial |
$277.97
|
| Rate for Payer: Cash Price |
$193.03
|
| Rate for Payer: Cigna All Commercial |
$277.64
|
| Rate for Payer: CORVEL All Commercial |
$299.20
|
| Rate for Payer: Coventry All Commercial |
$283.11
|
| Rate for Payer: Encore All Commercial |
$296.14
|
| Rate for Payer: Frontpath All Commercial |
$295.98
|
| Rate for Payer: Humana ChoiceCare |
$277.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$289.55
|
| Rate for Payer: PHCS All Commercial |
$241.29
|
| Rate for Payer: PHP All Commercial |
$243.99
|
| Rate for Payer: Sagamore Health Network All Products |
$248.37
|
| Rate for Payer: Signature Care EPO |
$267.03
|
| Rate for Payer: Signature Care PPO |
$283.11
|
| Rate for Payer: United Healthcare Commercial |
$253.52
|
|
|
THROMBIN (BOVINE) 5000 UNITS TOP SOLR
|
Facility
|
OP
|
$321.72
|
|
|
Service Code
|
NDC 60793021505
|
| Hospital Charge Code |
119314
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$299.20 |
| Rate for Payer: Aetna Commercial |
$271.53
|
| Rate for Payer: Aetna Medicare |
$102.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$99.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$184.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$201.11
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$118.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$113.25
|
| Rate for Payer: Cash Price |
$193.03
|
| Rate for Payer: Cash Price |
$193.03
|
| Rate for Payer: Centivo All Commercial |
$175.02
|
| Rate for Payer: Cigna All Commercial |
$277.64
|
| Rate for Payer: CORVEL All Commercial |
$299.20
|
| Rate for Payer: Coventry All Commercial |
$283.11
|
| Rate for Payer: Encore All Commercial |
$296.14
|
| Rate for Payer: Frontpath All Commercial |
$295.98
|
| Rate for Payer: Humana ChoiceCare |
$277.87
|
| Rate for Payer: Humana Medicare |
$102.95
|
| Rate for Payer: Lucent All Commercial |
$175.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$289.55
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$241.29
|
| Rate for Payer: PHP All Commercial |
$243.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$125.47
|
| Rate for Payer: Sagamore Health Network All Products |
$248.37
|
| Rate for Payer: Signature Care EPO |
$267.03
|
| Rate for Payer: Signature Care PPO |
$283.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$273.46
|
| Rate for Payer: United Healthcare Commercial |
$253.52
|
| Rate for Payer: United Healthcare Medicare |
$102.95
|
|
|
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 |
$294.12
|
| 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 |
$9.56 |
| Max. Negotiated Rate |
$455.89 |
| Rate for Payer: Aetna Commercial |
$413.73
|
| Rate for Payer: Aetna Medicare |
$156.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$151.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$281.52
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$306.42
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$180.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$172.55
|
| Rate for Payer: Cash Price |
$294.12
|
| Rate for Payer: Cash Price |
$294.12
|
| Rate for Payer: Centivo All Commercial |
$266.67
|
| 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 |
$156.86
|
| Rate for Payer: Lucent All Commercial |
$266.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$441.18
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| 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 |
$156.86
|
|
