|
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 |
$13.50
|
| 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 |
$0.72
|
| 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 |
$0.72
|
| 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
|
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 |
$199.47
|
| Rate for Payer: Cash Price |
$199.47
|
| 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 (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 |
$199.47
|
| 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 (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 |
$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 |
$303.92
|
| Rate for Payer: Cash Price |
$303.92
|
| 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
|
|
|
TICAGRELOR 90 MG ORAL TAB
|
Facility
|
OP
|
$50.58
|
|
|
Service Code
|
NDC 00186077760
|
| Hospital Charge Code |
152687
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$47.04 |
| Rate for Payer: Aetna Commercial |
$42.69
|
| Rate for Payer: Aetna Medicare |
$16.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$29.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.80
|
| Rate for Payer: Cash Price |
$31.36
|
| Rate for Payer: Centivo All Commercial |
$27.52
|
| Rate for Payer: Cigna All Commercial |
$43.65
|
| Rate for Payer: CORVEL All Commercial |
$47.04
|
| Rate for Payer: Coventry All Commercial |
$44.51
|
| Rate for Payer: Encore All Commercial |
$46.56
|
| Rate for Payer: Frontpath All Commercial |
$46.54
|
| Rate for Payer: Humana ChoiceCare |
$43.69
|
| Rate for Payer: Humana Medicare |
$16.19
|
| Rate for Payer: Lucent All Commercial |
$27.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.52
|
| Rate for Payer: PHCS All Commercial |
$37.94
|
| Rate for Payer: PHP All Commercial |
$38.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.73
|
| Rate for Payer: Sagamore Health Network All Products |
$39.05
|
| Rate for Payer: Signature Care EPO |
$41.98
|
| Rate for Payer: Signature Care PPO |
$44.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$42.99
|
| Rate for Payer: United Healthcare Commercial |
$39.86
|
| Rate for Payer: United Healthcare Medicare |
$16.19
|
|
|
TICAGRELOR 90 MG ORAL TAB
|
Facility
|
IP
|
$50.58
|
|
|
Service Code
|
NDC 00186077760
|
| Hospital Charge Code |
152687
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.94 |
| Max. Negotiated Rate |
$47.04 |
| Rate for Payer: Aetna Commercial |
$43.70
|
| Rate for Payer: Cash Price |
$31.36
|
| Rate for Payer: Cigna All Commercial |
$43.65
|
| Rate for Payer: CORVEL All Commercial |
$47.04
|
| Rate for Payer: Coventry All Commercial |
$44.51
|
| Rate for Payer: Encore All Commercial |
$46.56
|
| Rate for Payer: Frontpath All Commercial |
$46.54
|
| Rate for Payer: Humana ChoiceCare |
$43.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.52
|
| Rate for Payer: PHCS All Commercial |
$37.94
|
| Rate for Payer: PHP All Commercial |
$38.36
|
| Rate for Payer: Sagamore Health Network All Products |
$39.05
|
| Rate for Payer: Signature Care EPO |
$41.98
|
| Rate for Payer: Signature Care PPO |
$44.51
|
| Rate for Payer: United Healthcare Commercial |
$39.86
|
|
|
TIGECYCLINE 50 MG IV SOLR
|
Facility
|
IP
|
$128.78
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
41652
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.58 |
| Max. Negotiated Rate |
$119.76 |
| Rate for Payer: Aetna Commercial |
$111.27
|
| Rate for Payer: Cash Price |
$79.84
|
| Rate for Payer: Cigna All Commercial |
$111.14
|
| Rate for Payer: CORVEL All Commercial |
$119.76
|
| Rate for Payer: Coventry All Commercial |
$113.33
|
| Rate for Payer: Encore All Commercial |
$118.54
|
| Rate for Payer: Frontpath All Commercial |
$118.48
|
| Rate for Payer: Humana ChoiceCare |
$111.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$115.90
|
| Rate for Payer: PHCS All Commercial |
$96.58
|
| Rate for Payer: PHP All Commercial |
$97.67
|
| Rate for Payer: Sagamore Health Network All Products |
$99.42
|
| Rate for Payer: Signature Care EPO |
$106.89
|
| Rate for Payer: Signature Care PPO |
$113.33
|
| Rate for Payer: United Healthcare Commercial |
$101.48
|
|
|
TIGECYCLINE 50 MG IV SOLR
|
Facility
|
OP
|
$128.78
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
41652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$119.76 |
| Rate for Payer: Aetna Commercial |
$108.69
|
| Rate for Payer: Aetna Medicare |
$41.21
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$39.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$73.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$80.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$0.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$47.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$45.33
|
| Rate for Payer: Cash Price |
$79.84
|
| Rate for Payer: Cash Price |
$79.84
|
| Rate for Payer: Centivo All Commercial |
$70.06
|
| Rate for Payer: Cigna All Commercial |
$111.14
|
| Rate for Payer: CORVEL All Commercial |
$119.76
|
| Rate for Payer: Coventry All Commercial |
$113.33
|
| Rate for Payer: Encore All Commercial |
$118.54
|
| Rate for Payer: Frontpath All Commercial |
$118.48
|
| Rate for Payer: Humana ChoiceCare |
$111.23
|
| Rate for Payer: Humana Medicare |
$41.21
|
| Rate for Payer: Lucent All Commercial |
$70.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$115.90
|
| Rate for Payer: Managed Health Services Medicaid |
$0.41
|
| Rate for Payer: MDWise Medicaid |
$0.41
|
| Rate for Payer: PHCS All Commercial |
$96.58
|
| Rate for Payer: PHP All Commercial |
$97.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$50.22
|
| Rate for Payer: Sagamore Health Network All Products |
$99.42
|
| Rate for Payer: Signature Care EPO |
$106.89
|
| Rate for Payer: Signature Care PPO |
$113.33
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$109.46
|
| Rate for Payer: United Healthcare Commercial |
$101.48
|
| Rate for Payer: United Healthcare Medicare |
$41.21
|
|
|
TILDRAKIZUMAB-ASMN 100 MG/ML SUBQ SYRG
|
Facility
|
IP
|
$66,008.29
|
|
|
Service Code
|
HCPCS J3245
|
| Hospital Charge Code |
185525
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49,506.21 |
| Max. Negotiated Rate |
$61,387.71 |
| Rate for Payer: Aetna Commercial |
$57,031.16
|
| Rate for Payer: Cash Price |
$40,925.14
|
| Rate for Payer: Cigna All Commercial |
$56,965.15
|
| Rate for Payer: CORVEL All Commercial |
$61,387.71
|
| Rate for Payer: Coventry All Commercial |
$58,087.29
|
| Rate for Payer: Encore All Commercial |
$60,760.63
|
| Rate for Payer: Frontpath All Commercial |
$60,727.62
|
| Rate for Payer: Humana ChoiceCare |
$57,011.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59,407.46
|
| Rate for Payer: PHCS All Commercial |
$49,506.21
|
| Rate for Payer: PHP All Commercial |
$50,060.68
|
| Rate for Payer: Sagamore Health Network All Products |
$50,958.40
|
| Rate for Payer: Signature Care EPO |
$54,786.88
|
| Rate for Payer: Signature Care PPO |
$58,087.29
|
| Rate for Payer: United Healthcare Commercial |
$52,014.53
|
|
|
TILDRAKIZUMAB-ASMN 100 MG/ML SUBQ SYRG
|
Facility
|
OP
|
$66,008.29
|
|
|
Service Code
|
HCPCS J3245
|
| Hospital Charge Code |
185525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$188.60 |
| Max. Negotiated Rate |
$61,387.71 |
| Rate for Payer: Aetna Commercial |
$55,710.99
|
| Rate for Payer: Aetna Medicare |
$21,122.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$188.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$20,462.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$37,908.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$41,261.78
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$188.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$24,291.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$23,234.92
|
| Rate for Payer: Cash Price |
$40,925.14
|
| Rate for Payer: Cash Price |
$40,925.14
|
| Rate for Payer: Centivo All Commercial |
$35,908.51
|
| Rate for Payer: Cigna All Commercial |
$56,965.15
|
| Rate for Payer: CORVEL All Commercial |
$61,387.71
|
| Rate for Payer: Coventry All Commercial |
$58,087.29
|
| Rate for Payer: Encore All Commercial |
$60,760.63
|
| Rate for Payer: Frontpath All Commercial |
$60,727.62
|
| Rate for Payer: Humana ChoiceCare |
$57,011.36
|
| Rate for Payer: Humana Medicare |
$21,122.65
|
| Rate for Payer: Lucent All Commercial |
$35,908.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59,407.46
|
| Rate for Payer: Managed Health Services Medicaid |
$188.60
|
| Rate for Payer: MDWise Medicaid |
$188.60
|
| Rate for Payer: PHCS All Commercial |
$49,506.21
|
| Rate for Payer: PHP All Commercial |
$50,060.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$25,743.23
|
| Rate for Payer: Sagamore Health Network All Products |
$50,958.40
|
| Rate for Payer: Signature Care EPO |
$54,786.88
|
| Rate for Payer: Signature Care PPO |
$58,087.29
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$56,107.04
|
| Rate for Payer: United Healthcare Commercial |
$52,014.53
|
| Rate for Payer: United Healthcare Medicare |
$21,122.65
|
|
|
TIMOLOL MALEATE 0.25 % OPHT DROP
|
Facility
|
OP
|
$17.29
|
|
|
Service Code
|
NDC 61314022605
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.36 |
| Max. Negotiated Rate |
$16.08 |
| Rate for Payer: Aetna Commercial |
$14.59
|
| Rate for Payer: Aetna Medicare |
$5.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$9.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.09
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Centivo All Commercial |
$9.41
|
| Rate for Payer: Cigna All Commercial |
$14.92
|
| Rate for Payer: CORVEL All Commercial |
$16.08
|
| Rate for Payer: Coventry All Commercial |
$15.22
|
| Rate for Payer: Encore All Commercial |
$15.92
|
| Rate for Payer: Frontpath All Commercial |
$15.91
|
| Rate for Payer: Humana ChoiceCare |
$14.93
|
| Rate for Payer: Humana Medicare |
$5.53
|
| Rate for Payer: Lucent All Commercial |
$9.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.56
|
| Rate for Payer: PHCS All Commercial |
$12.97
|
| Rate for Payer: PHP All Commercial |
$13.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.74
|
| Rate for Payer: Sagamore Health Network All Products |
$13.35
|
| Rate for Payer: Signature Care EPO |
$14.35
|
| Rate for Payer: Signature Care PPO |
$15.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$14.70
|
| Rate for Payer: United Healthcare Commercial |
$13.62
|
| Rate for Payer: United Healthcare Medicare |
$5.53
|
|
|
TIMOLOL MALEATE 0.25 % OPHT DROP
|
Facility
|
IP
|
$17.29
|
|
|
Service Code
|
NDC 61314022605
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.97 |
| Max. Negotiated Rate |
$16.08 |
| Rate for Payer: Aetna Commercial |
$14.94
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Cigna All Commercial |
$14.92
|
| Rate for Payer: CORVEL All Commercial |
$16.08
|
| Rate for Payer: Coventry All Commercial |
$15.22
|
| Rate for Payer: Encore All Commercial |
$15.92
|
| Rate for Payer: Frontpath All Commercial |
$15.91
|
| Rate for Payer: Humana ChoiceCare |
$14.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.56
|
| Rate for Payer: PHCS All Commercial |
$12.97
|
| Rate for Payer: PHP All Commercial |
$13.11
|
| Rate for Payer: Sagamore Health Network All Products |
$13.35
|
| Rate for Payer: Signature Care EPO |
$14.35
|
| Rate for Payer: Signature Care PPO |
$15.22
|
| Rate for Payer: United Healthcare Commercial |
$13.62
|
|
|
TIMOLOL MALEATE 0.5 % OPHT DROP
|
Facility
|
OP
|
$38.92
|
|
|
Service Code
|
NDC 61314022705
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$36.20 |
| Rate for Payer: Aetna Commercial |
$32.85
|
| Rate for Payer: Aetna Medicare |
$12.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$22.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.33
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.70
|
| Rate for Payer: Cash Price |
$24.13
|
| Rate for Payer: Cash Price |
$24.13
|
| Rate for Payer: Centivo All Commercial |
$21.17
|
| Rate for Payer: Cigna All Commercial |
$33.59
|
| Rate for Payer: CORVEL All Commercial |
$36.20
|
| Rate for Payer: Coventry All Commercial |
$34.25
|
| Rate for Payer: Encore All Commercial |
$35.83
|
| Rate for Payer: Frontpath All Commercial |
$35.81
|
| Rate for Payer: Humana ChoiceCare |
$33.62
|
| Rate for Payer: Humana Medicare |
$12.45
|
| Rate for Payer: Lucent All Commercial |
$21.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.03
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$29.19
|
| Rate for Payer: PHP All Commercial |
$29.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.18
|
| Rate for Payer: Sagamore Health Network All Products |
$30.05
|
| Rate for Payer: Signature Care EPO |
$32.30
|
| Rate for Payer: Signature Care PPO |
$34.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$33.08
|
| Rate for Payer: United Healthcare Commercial |
$30.67
|
| Rate for Payer: United Healthcare Medicare |
$12.45
|
|
|
TIMOLOL MALEATE 0.5 % OPHT DROP
|
Facility
|
IP
|
$38.92
|
|
|
Service Code
|
NDC 61314022705
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.19 |
| Max. Negotiated Rate |
$36.20 |
| Rate for Payer: Aetna Commercial |
$33.63
|
| Rate for Payer: Cash Price |
$24.13
|
| Rate for Payer: Cigna All Commercial |
$33.59
|
| Rate for Payer: CORVEL All Commercial |
$36.20
|
| Rate for Payer: Coventry All Commercial |
$34.25
|
| Rate for Payer: Encore All Commercial |
$35.83
|
| Rate for Payer: Frontpath All Commercial |
$35.81
|
| Rate for Payer: Humana ChoiceCare |
$33.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.03
|
| Rate for Payer: PHCS All Commercial |
$29.19
|
| Rate for Payer: PHP All Commercial |
$29.52
|
| Rate for Payer: Sagamore Health Network All Products |
$30.05
|
| Rate for Payer: Signature Care EPO |
$32.30
|
| Rate for Payer: Signature Care PPO |
$34.25
|
| Rate for Payer: United Healthcare Commercial |
$30.67
|
|
|
TIOTROPIUM-OLODATEROL 2.5-2.5 MCG/ACTUATION INHL MIST
|
Facility
|
OP
|
$997.61
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
172695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$309.26 |
| Max. Negotiated Rate |
$927.78 |
| Rate for Payer: Aetna Commercial |
$841.98
|
| Rate for Payer: Aetna Medicare |
$319.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$309.26
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$572.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$623.61
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$367.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$351.16
|
| Rate for Payer: Cash Price |
$618.52
|
| Rate for Payer: Centivo All Commercial |
$542.70
|
| Rate for Payer: Cigna All Commercial |
$860.94
|
| Rate for Payer: CORVEL All Commercial |
$927.78
|
| Rate for Payer: Coventry All Commercial |
$877.90
|
| Rate for Payer: Encore All Commercial |
$918.30
|
| Rate for Payer: Frontpath All Commercial |
$917.80
|
| Rate for Payer: Humana ChoiceCare |
$861.64
|
| Rate for Payer: Humana Medicare |
$319.24
|
| Rate for Payer: Lucent All Commercial |
$542.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$897.85
|
| Rate for Payer: PHCS All Commercial |
$748.21
|
| Rate for Payer: PHP All Commercial |
$756.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$389.07
|
| Rate for Payer: Sagamore Health Network All Products |
$770.16
|
| Rate for Payer: Signature Care EPO |
$828.02
|
| Rate for Payer: Signature Care PPO |
$877.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$847.97
|
| Rate for Payer: United Healthcare Commercial |
$786.12
|
| Rate for Payer: United Healthcare Medicare |
$319.24
|
|
|
TIOTROPIUM-OLODATEROL 2.5-2.5 MCG/ACTUATION INHL MIST
|
Facility
|
IP
|
$997.61
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
172695
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$748.21 |
| Max. Negotiated Rate |
$927.78 |
| Rate for Payer: Aetna Commercial |
$861.94
|
| Rate for Payer: Cash Price |
$618.52
|
| Rate for Payer: Cigna All Commercial |
$860.94
|
| Rate for Payer: CORVEL All Commercial |
$927.78
|
| Rate for Payer: Coventry All Commercial |
$877.90
|
| Rate for Payer: Encore All Commercial |
$918.30
|
| Rate for Payer: Frontpath All Commercial |
$917.80
|
| Rate for Payer: Humana ChoiceCare |
$861.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$897.85
|
| Rate for Payer: PHCS All Commercial |
$748.21
|
| Rate for Payer: PHP All Commercial |
$756.59
|
| Rate for Payer: Sagamore Health Network All Products |
$770.16
|
| Rate for Payer: Signature Care EPO |
$828.02
|
| Rate for Payer: Signature Care PPO |
$877.90
|
| Rate for Payer: United Healthcare Commercial |
$786.12
|
|
|
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/Pathway |
$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 |
$0.00
|
| 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
|
$2.49
|
|
|
Service Code
|
NDC 00904641861
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna Commercial |
$2.10
|
| Rate for Payer: Aetna Medicare |
$0.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.87
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Centivo All Commercial |
$1.35
|
| Rate for Payer: Cigna All Commercial |
$2.14
|
| Rate for Payer: CORVEL All Commercial |
$2.31
|
| Rate for Payer: Coventry All Commercial |
$2.19
|
| Rate for Payer: Encore All Commercial |
$2.29
|
| Rate for Payer: Frontpath All Commercial |
$2.29
|
| Rate for Payer: Humana ChoiceCare |
$2.15
|
| Rate for Payer: Humana Medicare |
$0.80
|
| Rate for Payer: Lucent All Commercial |
$1.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.24
|
| Rate for Payer: PHCS All Commercial |
$1.86
|
| Rate for Payer: PHP All Commercial |
$1.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.97
|
| Rate for Payer: Sagamore Health Network All Products |
$1.92
|
| Rate for Payer: Signature Care EPO |
$2.06
|
| Rate for Payer: Signature Care PPO |
$2.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.11
|
| Rate for Payer: United Healthcare Commercial |
$1.96
|
| Rate for Payer: United Healthcare Medicare |
$0.80
|
|
|
TIZANIDINE 4 MG ORAL TAB
|
Facility
|
IP
|
$2.49
|
|
|
Service Code
|
NDC 00904641861
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna Commercial |
$2.15
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Cigna All Commercial |
$2.14
|
| Rate for Payer: CORVEL All Commercial |
$2.31
|
| Rate for Payer: Coventry All Commercial |
$2.19
|
| Rate for Payer: Encore All Commercial |
$2.29
|
| Rate for Payer: Frontpath All Commercial |
$2.29
|
| Rate for Payer: Humana ChoiceCare |
$2.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.24
|
| Rate for Payer: PHCS All Commercial |
$1.86
|
| Rate for Payer: PHP All Commercial |
$1.88
|
| Rate for Payer: Sagamore Health Network All Products |
$1.92
|
| Rate for Payer: Signature Care EPO |
$2.06
|
| Rate for Payer: Signature Care PPO |
$2.19
|
| Rate for Payer: United Healthcare Commercial |
$1.96
|
|
|
TOBRAMYCIN 0.3 % OPHT DROP
|
Facility
|
OP
|
$15.40
|
|
|
Service Code
|
NDC 62332051805
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.77 |
| Max. Negotiated Rate |
$14.32 |
| Rate for Payer: Aetna Commercial |
$13.00
|
| Rate for Payer: Aetna Medicare |
$4.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.42
|
| Rate for Payer: Cash Price |
$9.55
|
| Rate for Payer: Cash Price |
$9.55
|
| Rate for Payer: Centivo All Commercial |
$8.38
|
| Rate for Payer: Cigna All Commercial |
$13.29
|
| Rate for Payer: CORVEL All Commercial |
$14.32
|
| Rate for Payer: Coventry All Commercial |
$13.55
|
| Rate for Payer: Encore All Commercial |
$14.18
|
| Rate for Payer: Frontpath All Commercial |
$14.17
|
| Rate for Payer: Humana ChoiceCare |
$13.30
|
| Rate for Payer: Humana Medicare |
$4.93
|
| Rate for Payer: Lucent All Commercial |
$8.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.86
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$11.55
|
| Rate for Payer: PHP All Commercial |
$11.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.01
|
| Rate for Payer: Sagamore Health Network All Products |
$11.89
|
| Rate for Payer: Signature Care EPO |
$12.78
|
| Rate for Payer: Signature Care PPO |
$13.55
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13.09
|
| Rate for Payer: United Healthcare Commercial |
$12.14
|
| Rate for Payer: United Healthcare Medicare |
$4.93
|
|
|
TOBRAMYCIN 0.3 % OPHT DROP
|
Facility
|
IP
|
$15.40
|
|
|
Service Code
|
NDC 62332051805
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$14.32 |
| Rate for Payer: Aetna Commercial |
$13.31
|
| Rate for Payer: Cash Price |
$9.55
|
| Rate for Payer: Cigna All Commercial |
$13.29
|
| Rate for Payer: CORVEL All Commercial |
$14.32
|
| Rate for Payer: Coventry All Commercial |
$13.55
|
| Rate for Payer: Encore All Commercial |
$14.18
|
| Rate for Payer: Frontpath All Commercial |
$14.17
|
| Rate for Payer: Humana ChoiceCare |
$13.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.86
|
| Rate for Payer: PHCS All Commercial |
$11.55
|
| Rate for Payer: PHP All Commercial |
$11.68
|
| Rate for Payer: Sagamore Health Network All Products |
$11.89
|
| Rate for Payer: Signature Care EPO |
$12.78
|
| Rate for Payer: Signature Care PPO |
$13.55
|
| Rate for Payer: United Healthcare Commercial |
$12.14
|
|
