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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ

Facility

IP

$88.44

Service Code	HCPCS 90714
Hospital Charge Code	4928121510
Hospital Revenue Code	250
Min. Negotiated Rate	$44.22
Max. Negotiated Rate	$44.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.22

TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ

Facility

OP

$88.44

Service Code	HCPCS 90714
Hospital Charge Code	4928121588
Hospital Revenue Code	250
Min. Negotiated Rate	$26.22
Max. Negotiated Rate	$70.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$48.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26.22
Rate for Payer: Aetna Government	$26.22
Rate for Payer: Brighton Health Commercial	$66.33
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$70.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$60.14
Rate for Payer: EmblemHealth Commercial	$44.22
Rate for Payer: Group Health Inc Commercial	$44.22
Rate for Payer: Group Health Inc Medicare	$30.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.22
Rate for Payer: Hamaspik Choice Inc Medicare	$44.22
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$37.37
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$57.49

TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ

Facility

IP

$88.44

Service Code	HCPCS 90714
Hospital Charge Code	4928121588
Hospital Revenue Code	250
Min. Negotiated Rate	$44.22
Max. Negotiated Rate	$44.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.22

TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ

Facility

OP

$88.44

Service Code	HCPCS 90714
Hospital Charge Code	4928121558
Hospital Revenue Code	250
Min. Negotiated Rate	$26.22
Max. Negotiated Rate	$70.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$48.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26.22
Rate for Payer: Aetna Government	$26.22
Rate for Payer: Brighton Health Commercial	$66.33
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$70.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$60.14
Rate for Payer: EmblemHealth Commercial	$44.22
Rate for Payer: Group Health Inc Commercial	$44.22
Rate for Payer: Group Health Inc Medicare	$30.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.22
Rate for Payer: Hamaspik Choice Inc Medicare	$44.22
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$37.37
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$57.49

TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ

Facility

IP

$88.44

Service Code	HCPCS 90714
Hospital Charge Code	4928121558
Hospital Revenue Code	250
Min. Negotiated Rate	$44.22
Max. Negotiated Rate	$44.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.22

TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ

Facility

OP

$88.44

Service Code	HCPCS 90714
Hospital Charge Code	4928121515
Hospital Revenue Code	250
Min. Negotiated Rate	$26.22
Max. Negotiated Rate	$70.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$48.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26.22
Rate for Payer: Aetna Government	$26.22
Rate for Payer: Brighton Health Commercial	$66.33
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$70.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$60.14
Rate for Payer: EmblemHealth Commercial	$44.22
Rate for Payer: Group Health Inc Commercial	$44.22
Rate for Payer: Group Health Inc Medicare	$30.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.22
Rate for Payer: Hamaspik Choice Inc Medicare	$44.22
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$37.37
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$57.49

TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ

Facility

IP

$88.44

Service Code	HCPCS 90714
Hospital Charge Code	4928121515
Hospital Revenue Code	250
Min. Negotiated Rate	$44.22
Max. Negotiated Rate	$44.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.22

TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ

Facility

OP

$88.44

Service Code	HCPCS 90714
Hospital Charge Code	4928121510
Hospital Revenue Code	250
Min. Negotiated Rate	$26.22
Max. Negotiated Rate	$70.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$48.64
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26.22
Rate for Payer: Aetna Government	$26.22
Rate for Payer: Brighton Health Commercial	$66.33
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$70.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$60.14
Rate for Payer: EmblemHealth Commercial	$44.22
Rate for Payer: Group Health Inc Commercial	$44.22
Rate for Payer: Group Health Inc Medicare	$30.96
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.22
Rate for Payer: Hamaspik Choice Inc Medicare	$44.22
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$37.37
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$57.49

TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY

Facility

OP

$779.00

Service Code	HCPCS J1670
Hospital Charge Code	1353363402
Hospital Revenue Code	250
Min. Negotiated Rate	$415.10
Max. Negotiated Rate	$623.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$428.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$593.00
Rate for Payer: Aetna Government	$593.00
Rate for Payer: Affinity Essential Plan 1&2	$415.10
Rate for Payer: Affinity Essential Plan 3&4	$415.10
Rate for Payer: Affinity Medicaid/CHP/HARP	$415.10
Rate for Payer: Brighton Health Commercial	$584.25
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$593.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$623.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$529.72
Rate for Payer: Elderplan Medicare Advantage	$593.00
Rate for Payer: EmblemHealth Commercial	$593.00
Rate for Payer: Fidelis CHP/HARP/Medicaid	$533.70
Rate for Payer: Fidelis Essential Plan Aliesa	$504.05
Rate for Payer: Fidelis Essential Plan QHP	$527.77
Rate for Payer: Fidelis Medicare Advantage	$593.00
Rate for Payer: Fidelis Qualified Health Plan	$527.77
Rate for Payer: Group Health Inc Commercial	$593.00
Rate for Payer: Group Health Inc Medicare	$593.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$593.00
Rate for Payer: Hamaspik Choice Inc Medicare	$593.00
Rate for Payer: Healthfirst CHP/FHP/Medicaid	$593.00
Rate for Payer: Healthfirst Medicare Advantage	$504.05
Rate for Payer: Healthfirst QHP	$593.00
Rate for Payer: Humana Medicare	$604.86
Rate for Payer: Senior Whole Health Medicare Advantage	$593.00
Rate for Payer: United Healthcare Medicare Advantage	$593.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$506.35
Rate for Payer: Wellcare CHP/FHP/Medicaid	$563.35
Rate for Payer: Wellcare Medicare	$563.35

TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY

Facility

IP

$779.00

Service Code	HCPCS J1670
Hospital Charge Code	1353363402
Hospital Revenue Code	250
Min. Negotiated Rate	$389.50
Max. Negotiated Rate	$389.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$389.50

TETRACAINE HCL 0.5 % OP SOLN

Facility

OP

$7.20

Service Code	NDC 6868292005
Hospital Charge Code	6868292005
Hospital Revenue Code	250
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.60
Rate for Payer: Aetna Government	$3.60
Rate for Payer: Brighton Health Commercial	$5.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.90
Rate for Payer: EmblemHealth Commercial	$3.60
Rate for Payer: Group Health Inc Commercial	$3.60
Rate for Payer: Group Health Inc Medicare	$2.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.60
Rate for Payer: Hamaspik Choice Inc Medicare	$3.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.68

TETRACAINE HCL 0.5 % OP SOLN

Facility

IP

$7.20

Service Code	NDC 6868292005
Hospital Charge Code	6868292005
Hospital Revenue Code	250
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$3.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.60

TETRACAINE HCL 0.5 % OP SOLN

Facility

IP

$3.97

Service Code	NDC 0065074114
Hospital Charge Code	0065074114
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$1.98
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.98

TETRACAINE HCL 0.5 % OP SOLN

Facility

OP

$7.20

Service Code	NDC 6868292064
Hospital Charge Code	6868292064
Hospital Revenue Code	250
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.76
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.96
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.60
Rate for Payer: Aetna Government	$3.60
Rate for Payer: Brighton Health Commercial	$5.40
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.76
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.90
Rate for Payer: EmblemHealth Commercial	$3.60
Rate for Payer: Group Health Inc Commercial	$3.60
Rate for Payer: Group Health Inc Medicare	$2.52
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.60
Rate for Payer: Hamaspik Choice Inc Medicare	$3.60
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.68

TETRACAINE HCL 0.5 % OP SOLN

Facility

OP

$3.97

Service Code	NDC 0065074114
Hospital Charge Code	0065074114
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$3.17
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.98
Rate for Payer: Aetna Government	$1.98
Rate for Payer: Brighton Health Commercial	$2.97
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.17
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.70
Rate for Payer: EmblemHealth Commercial	$1.98
Rate for Payer: Group Health Inc Commercial	$1.98
Rate for Payer: Group Health Inc Medicare	$1.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.98
Rate for Payer: Hamaspik Choice Inc Medicare	$1.98
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.58

TETRACAINE HCL 0.5 % OP SOLN

Facility

IP

$7.20

Service Code	NDC 6868292064
Hospital Charge Code	6868292064
Hospital Revenue Code	250
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$3.60
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.60

TETRACAINE HCL 1 % IJ SOLN

Facility

IP

$45.52

Service Code	NDC 4249443710
Hospital Charge Code	4249443710
Hospital Revenue Code	250
Min. Negotiated Rate	$22.76
Max. Negotiated Rate	$22.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.76

TETRACAINE HCL 1 % IJ SOLN

Facility

OP

$45.52

Service Code	NDC 5428812710
Hospital Charge Code	5428812710
Hospital Revenue Code	250
Min. Negotiated Rate	$15.93
Max. Negotiated Rate	$36.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$25.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$22.76
Rate for Payer: Aetna Government	$22.76
Rate for Payer: Brighton Health Commercial	$34.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$36.41
Rate for Payer: Cigna LocalPlus Benefit Plan	$30.95
Rate for Payer: EmblemHealth Commercial	$22.76
Rate for Payer: Group Health Inc Commercial	$22.76
Rate for Payer: Group Health Inc Medicare	$15.93
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.76
Rate for Payer: Hamaspik Choice Inc Medicare	$22.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$29.58

TETRACAINE HCL 1 % IJ SOLN

Facility

OP

$45.52

Service Code	NDC 4249443710
Hospital Charge Code	4249443710
Hospital Revenue Code	250
Min. Negotiated Rate	$15.93
Max. Negotiated Rate	$36.41
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$25.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$22.76
Rate for Payer: Aetna Government	$22.76
Rate for Payer: Brighton Health Commercial	$34.14
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$36.41
Rate for Payer: Cigna LocalPlus Benefit Plan	$30.95
Rate for Payer: EmblemHealth Commercial	$22.76
Rate for Payer: Group Health Inc Commercial	$22.76
Rate for Payer: Group Health Inc Medicare	$15.93
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.76
Rate for Payer: Hamaspik Choice Inc Medicare	$22.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$29.58

TETRACAINE HCL 1 % IJ SOLN

Facility

IP

$45.52

Service Code	NDC 5428812710
Hospital Charge Code	5428812710
Hospital Revenue Code	250
Min. Negotiated Rate	$22.76
Max. Negotiated Rate	$22.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$22.76

TETRACYCLINE HCL 250 MG PO CAPS

Facility

OP

$7.88

Service Code	NDC 6021915221
Hospital Charge Code	6021915221
Hospital Revenue Code	250
Min. Negotiated Rate	$2.76
Max. Negotiated Rate	$6.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.94
Rate for Payer: Aetna Government	$3.94
Rate for Payer: Brighton Health Commercial	$5.91
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$6.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$5.36
Rate for Payer: EmblemHealth Commercial	$3.94
Rate for Payer: Group Health Inc Commercial	$3.94
Rate for Payer: Group Health Inc Medicare	$2.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.94
Rate for Payer: Hamaspik Choice Inc Medicare	$3.94
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.12

TETRACYCLINE HCL 250 MG PO CAPS

Facility

IP

$7.88

Service Code	NDC 6021915221
Hospital Charge Code	6021915221
Hospital Revenue Code	250
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$3.94
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.94

TETRACYCLINE HCL 500 MG PO CAPS

Facility

IP

$15.75

Service Code	NDC 5199190701
Hospital Charge Code	5199190701
Hospital Revenue Code	250
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$7.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.88

TETRACYCLINE HCL 500 MG PO CAPS

Facility

OP

$15.75

Service Code	NDC 5199190701
Hospital Charge Code	5199190701
Hospital Revenue Code	250
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$12.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.88
Rate for Payer: Aetna Government	$7.88
Rate for Payer: Brighton Health Commercial	$11.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.71
Rate for Payer: EmblemHealth Commercial	$7.88
Rate for Payer: Group Health Inc Commercial	$7.88
Rate for Payer: Group Health Inc Medicare	$5.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.88
Rate for Payer: Hamaspik Choice Inc Medicare	$7.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.24

TETRACYCLINE HCL 500 MG PO CAPS

Facility

OP

$15.75

Service Code	NDC 6923815231
Hospital Charge Code	6923815231
Hospital Revenue Code	250
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$12.60
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$8.66
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$7.88
Rate for Payer: Aetna Government	$7.88
Rate for Payer: Brighton Health Commercial	$11.81
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$12.60
Rate for Payer: Cigna LocalPlus Benefit Plan	$10.71
Rate for Payer: EmblemHealth Commercial	$7.88
Rate for Payer: Group Health Inc Commercial	$7.88
Rate for Payer: Group Health Inc Medicare	$5.51
Rate for Payer: Hamaspik Choice Inc Medicaid	$7.88
Rate for Payer: Hamaspik Choice Inc Medicare	$7.88
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$10.24