|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
OP
|
$427.70
|
|
|
Service Code
|
NDC 68084025301
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.58 |
| Max. Negotiated Rate |
$384.93 |
| Rate for Payer: Aetna Commercial |
$363.55
|
| Rate for Payer: Aetna Medicare |
$111.20
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$133.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$133.66
|
| Rate for Payer: BCBS Complete |
$171.08
|
| Rate for Payer: BCBS MAPPO |
$106.92
|
| Rate for Payer: BCBS Trust/PPO |
$351.61
|
| Rate for Payer: BCN Commercial |
$332.54
|
| Rate for Payer: BCN Medicare Advantage |
$106.92
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$367.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$106.92
|
| Rate for Payer: Healthscope Commercial |
$384.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$320.77
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$112.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$122.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$363.55
|
| Rate for Payer: Nomi Health Commercial |
$350.71
|
| Rate for Payer: PACE Senior Care Partners |
$101.58
|
| Rate for Payer: PACE SWMI |
$106.92
|
| Rate for Payer: PHP Commercial |
$363.55
|
| Rate for Payer: PHP Medicare Advantage |
$106.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.00
|
| Rate for Payer: Priority Health HMO/PPO |
$372.10
|
| Rate for Payer: Priority Health Medicare |
$107.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$286.56
|
| Rate for Payer: Railroad Medicare Medicare |
$106.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$376.38
|
| Rate for Payer: UHC Core |
$357.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$106.92
|
| Rate for Payer: UHC Exchange |
$106.92
|
| Rate for Payer: UHC Medicare Advantage |
$106.92
|
| Rate for Payer: VA VA |
$106.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$320.77
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
OP
|
$427.70
|
|
|
Service Code
|
NDC 68084025311
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.58 |
| Max. Negotiated Rate |
$384.93 |
| Rate for Payer: Aetna Commercial |
$363.55
|
| Rate for Payer: Aetna Medicare |
$111.20
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$133.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$133.66
|
| Rate for Payer: BCBS Complete |
$171.08
|
| Rate for Payer: BCBS MAPPO |
$106.92
|
| Rate for Payer: BCBS Trust/PPO |
$351.61
|
| Rate for Payer: BCN Commercial |
$332.54
|
| Rate for Payer: BCN Medicare Advantage |
$106.92
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$367.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$106.92
|
| Rate for Payer: Healthscope Commercial |
$384.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$320.77
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$112.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$122.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$363.55
|
| Rate for Payer: Nomi Health Commercial |
$350.71
|
| Rate for Payer: PACE Senior Care Partners |
$101.58
|
| Rate for Payer: PACE SWMI |
$106.92
|
| Rate for Payer: PHP Commercial |
$363.55
|
| Rate for Payer: PHP Medicare Advantage |
$106.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.00
|
| Rate for Payer: Priority Health HMO/PPO |
$372.10
|
| Rate for Payer: Priority Health Medicare |
$107.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$286.56
|
| Rate for Payer: Railroad Medicare Medicare |
$106.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$376.38
|
| Rate for Payer: UHC Core |
$357.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$106.92
|
| Rate for Payer: UHC Exchange |
$106.92
|
| Rate for Payer: UHC Medicare Advantage |
$106.92
|
| Rate for Payer: VA VA |
$106.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$320.77
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
IP
|
$352.50
|
|
|
Service Code
|
NDC 63739048310
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$229.12 |
| Max. Negotiated Rate |
$317.25 |
| Rate for Payer: Aetna Commercial |
$299.62
|
| Rate for Payer: BCBS Trust/PPO |
$287.75
|
| Rate for Payer: BCN Commercial |
$272.41
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cofinity Commercial |
$303.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.00
|
| Rate for Payer: Healthscope Commercial |
$317.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$264.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$299.62
|
| Rate for Payer: Nomi Health Commercial |
$289.05
|
| Rate for Payer: PHP Commercial |
$299.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.12
|
| Rate for Payer: Priority Health HMO/PPO |
$306.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$236.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$310.20
|
| Rate for Payer: UHC Core |
$294.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$264.38
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
IP
|
$178.60
|
|
|
Service Code
|
NDC 10702001001
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.09 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna Commercial |
$151.81
|
| Rate for Payer: BCBS Trust/PPO |
$145.79
|
| Rate for Payer: BCN Commercial |
$138.02
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$153.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.88
|
| Rate for Payer: Healthscope Commercial |
$160.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.81
|
| Rate for Payer: Nomi Health Commercial |
$146.45
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.09
|
| Rate for Payer: Priority Health HMO/PPO |
$155.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$119.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$157.17
|
| Rate for Payer: UHC Core |
$149.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.95
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
IP
|
$427.70
|
|
|
Service Code
|
NDC 68084025301
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.00 |
| Max. Negotiated Rate |
$384.93 |
| Rate for Payer: Aetna Commercial |
$363.55
|
| Rate for Payer: BCBS Trust/PPO |
$349.13
|
| Rate for Payer: BCN Commercial |
$330.53
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$367.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Healthscope Commercial |
$384.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$320.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$363.55
|
| Rate for Payer: Nomi Health Commercial |
$350.71
|
| Rate for Payer: PHP Commercial |
$363.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.00
|
| Rate for Payer: Priority Health HMO/PPO |
$372.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$286.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$376.38
|
| Rate for Payer: UHC Core |
$357.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$320.77
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
IP
|
$427.70
|
|
|
Service Code
|
NDC 68084025311
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.00 |
| Max. Negotiated Rate |
$384.93 |
| Rate for Payer: Aetna Commercial |
$363.55
|
| Rate for Payer: BCBS Trust/PPO |
$349.13
|
| Rate for Payer: BCN Commercial |
$330.53
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$367.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Healthscope Commercial |
$384.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$320.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$363.55
|
| Rate for Payer: Nomi Health Commercial |
$350.71
|
| Rate for Payer: PHP Commercial |
$363.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.00
|
| Rate for Payer: Priority Health HMO/PPO |
$372.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$286.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$376.38
|
| Rate for Payer: UHC Core |
$357.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$320.77
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
OP
|
$352.50
|
|
|
Service Code
|
NDC 63739048310
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.72 |
| Max. Negotiated Rate |
$317.25 |
| Rate for Payer: Aetna Commercial |
$299.62
|
| Rate for Payer: Aetna Medicare |
$91.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$110.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$110.16
|
| Rate for Payer: BCBS Complete |
$141.00
|
| Rate for Payer: BCBS MAPPO |
$88.12
|
| Rate for Payer: BCBS Trust/PPO |
$289.79
|
| Rate for Payer: BCN Commercial |
$274.07
|
| Rate for Payer: BCN Medicare Advantage |
$88.12
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cofinity Commercial |
$303.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$88.12
|
| Rate for Payer: Healthscope Commercial |
$317.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$264.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$92.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$101.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$299.62
|
| Rate for Payer: Nomi Health Commercial |
$289.05
|
| Rate for Payer: PACE Senior Care Partners |
$83.72
|
| Rate for Payer: PACE SWMI |
$88.12
|
| Rate for Payer: PHP Commercial |
$299.62
|
| Rate for Payer: PHP Medicare Advantage |
$88.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.12
|
| Rate for Payer: Priority Health HMO/PPO |
$306.68
|
| Rate for Payer: Priority Health Medicare |
$89.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$236.18
|
| Rate for Payer: Railroad Medicare Medicare |
$88.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$310.20
|
| Rate for Payer: UHC Core |
$294.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$88.12
|
| Rate for Payer: UHC Exchange |
$88.12
|
| Rate for Payer: UHC Medicare Advantage |
$88.12
|
| Rate for Payer: VA VA |
$88.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$264.38
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
OP
|
$178.60
|
|
|
Service Code
|
NDC 10702001001
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.42 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna Commercial |
$151.81
|
| Rate for Payer: Aetna Medicare |
$46.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$55.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$55.81
|
| Rate for Payer: BCBS Complete |
$71.44
|
| Rate for Payer: BCBS MAPPO |
$44.65
|
| Rate for Payer: BCBS Trust/PPO |
$146.83
|
| Rate for Payer: BCN Commercial |
$138.86
|
| Rate for Payer: BCN Medicare Advantage |
$44.65
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$153.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$44.65
|
| Rate for Payer: Healthscope Commercial |
$160.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$46.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$51.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.81
|
| Rate for Payer: Nomi Health Commercial |
$146.45
|
| Rate for Payer: PACE Senior Care Partners |
$42.42
|
| Rate for Payer: PACE SWMI |
$44.65
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: PHP Medicare Advantage |
$44.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.09
|
| Rate for Payer: Priority Health HMO/PPO |
$155.38
|
| Rate for Payer: Priority Health Medicare |
$45.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$119.66
|
| Rate for Payer: Railroad Medicare Medicare |
$44.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$157.17
|
| Rate for Payer: UHC Core |
$149.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$44.65
|
| Rate for Payer: UHC Exchange |
$44.65
|
| Rate for Payer: UHC Medicare Advantage |
$44.65
|
| Rate for Payer: VA VA |
$44.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.95
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
IP
|
$352.50
|
|
|
Service Code
|
NDC 00904661761
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$229.12 |
| Max. Negotiated Rate |
$317.25 |
| Rate for Payer: Aetna Commercial |
$299.62
|
| Rate for Payer: BCBS Trust/PPO |
$287.75
|
| Rate for Payer: BCN Commercial |
$272.41
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cofinity Commercial |
$303.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.00
|
| Rate for Payer: Healthscope Commercial |
$317.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$264.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$299.62
|
| Rate for Payer: Nomi Health Commercial |
$289.05
|
| Rate for Payer: PHP Commercial |
$299.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.12
|
| Rate for Payer: Priority Health HMO/PPO |
$306.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$236.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$310.20
|
| Rate for Payer: UHC Core |
$294.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$264.38
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
OP
|
$281.20
|
|
|
Service Code
|
NDC 68084025401
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.78 |
| Max. Negotiated Rate |
$253.08 |
| Rate for Payer: Aetna Commercial |
$239.02
|
| Rate for Payer: Aetna Medicare |
$73.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$87.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$87.88
|
| Rate for Payer: BCBS Complete |
$112.48
|
| Rate for Payer: BCBS MAPPO |
$70.30
|
| Rate for Payer: BCBS Trust/PPO |
$231.17
|
| Rate for Payer: BCN Commercial |
$218.63
|
| Rate for Payer: BCN Medicare Advantage |
$70.30
|
| Rate for Payer: Cash Price |
$224.96
|
| Rate for Payer: Cofinity Commercial |
$241.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$70.30
|
| Rate for Payer: Healthscope Commercial |
$253.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$73.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$80.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.02
|
| Rate for Payer: Nomi Health Commercial |
$230.58
|
| Rate for Payer: PACE Senior Care Partners |
$66.78
|
| Rate for Payer: PACE SWMI |
$70.30
|
| Rate for Payer: PHP Commercial |
$239.02
|
| Rate for Payer: PHP Medicare Advantage |
$70.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.78
|
| Rate for Payer: Priority Health HMO/PPO |
$244.64
|
| Rate for Payer: Priority Health Medicare |
$71.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$188.40
|
| Rate for Payer: Railroad Medicare Medicare |
$70.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$247.46
|
| Rate for Payer: UHC Core |
$234.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$70.30
|
| Rate for Payer: UHC Exchange |
$70.30
|
| Rate for Payer: UHC Medicare Advantage |
$70.30
|
| Rate for Payer: VA VA |
$70.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.90
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
OP
|
$352.50
|
|
|
Service Code
|
NDC 00904661761
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.72 |
| Max. Negotiated Rate |
$317.25 |
| Rate for Payer: Aetna Commercial |
$299.62
|
| Rate for Payer: Aetna Medicare |
$91.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$110.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$110.16
|
| Rate for Payer: BCBS Complete |
$141.00
|
| Rate for Payer: BCBS MAPPO |
$88.12
|
| Rate for Payer: BCBS Trust/PPO |
$289.79
|
| Rate for Payer: BCN Commercial |
$274.07
|
| Rate for Payer: BCN Medicare Advantage |
$88.12
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cofinity Commercial |
$303.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$88.12
|
| Rate for Payer: Healthscope Commercial |
$317.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$264.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$92.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$101.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$299.62
|
| Rate for Payer: Nomi Health Commercial |
$289.05
|
| Rate for Payer: PACE Senior Care Partners |
$83.72
|
| Rate for Payer: PACE SWMI |
$88.12
|
| Rate for Payer: PHP Commercial |
$299.62
|
| Rate for Payer: PHP Medicare Advantage |
$88.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.12
|
| Rate for Payer: Priority Health HMO/PPO |
$306.68
|
| Rate for Payer: Priority Health Medicare |
$89.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$236.18
|
| Rate for Payer: Railroad Medicare Medicare |
$88.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$310.20
|
| Rate for Payer: UHC Core |
$294.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$88.12
|
| Rate for Payer: UHC Exchange |
$88.12
|
| Rate for Payer: UHC Medicare Advantage |
$88.12
|
| Rate for Payer: VA VA |
$88.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$264.38
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
IP
|
$2.82
|
|
|
Service Code
|
NDC 68084025411
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: BCBS Trust/PPO |
$2.30
|
| Rate for Payer: BCN Commercial |
$2.18
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.26
|
| Rate for Payer: Healthscope Commercial |
$2.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.40
|
| Rate for Payer: Nomi Health Commercial |
$2.31
|
| Rate for Payer: PHP Commercial |
$2.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health HMO/PPO |
$2.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.48
|
| Rate for Payer: UHC Core |
$2.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.12
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
OP
|
$2.82
|
|
|
Service Code
|
NDC 68084025411
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: Aetna Medicare |
$0.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.88
|
| Rate for Payer: BCBS Complete |
$1.13
|
| Rate for Payer: BCBS MAPPO |
$0.71
|
| Rate for Payer: BCBS Trust/PPO |
$2.32
|
| Rate for Payer: BCN Commercial |
$2.19
|
| Rate for Payer: BCN Medicare Advantage |
$0.71
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.71
|
| Rate for Payer: Healthscope Commercial |
$2.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.40
|
| Rate for Payer: Nomi Health Commercial |
$2.31
|
| Rate for Payer: PACE Senior Care Partners |
$0.67
|
| Rate for Payer: PACE SWMI |
$0.71
|
| Rate for Payer: PHP Commercial |
$2.40
|
| Rate for Payer: PHP Medicare Advantage |
$0.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health HMO/PPO |
$2.45
|
| Rate for Payer: Priority Health Medicare |
$0.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.89
|
| Rate for Payer: Railroad Medicare Medicare |
$0.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.48
|
| Rate for Payer: UHC Core |
$2.35
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.71
|
| Rate for Payer: UHC Exchange |
$0.71
|
| Rate for Payer: UHC Medicare Advantage |
$0.71
|
| Rate for Payer: VA VA |
$0.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.12
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
IP
|
$281.20
|
|
|
Service Code
|
NDC 68084025401
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$182.78 |
| Max. Negotiated Rate |
$253.08 |
| Rate for Payer: Aetna Commercial |
$239.02
|
| Rate for Payer: BCBS Trust/PPO |
$229.54
|
| Rate for Payer: BCN Commercial |
$217.31
|
| Rate for Payer: Cash Price |
$224.96
|
| Rate for Payer: Cofinity Commercial |
$241.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.96
|
| Rate for Payer: Healthscope Commercial |
$253.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.02
|
| Rate for Payer: Nomi Health Commercial |
$230.58
|
| Rate for Payer: PHP Commercial |
$239.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.78
|
| Rate for Payer: Priority Health HMO/PPO |
$244.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$188.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$247.46
|
| Rate for Payer: UHC Core |
$234.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.90
|
|
|
HYOSCYAMINE 0.125 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$300.96
|
|
|
Service Code
|
NDC 43199001201
|
| Hospital Charge Code |
29822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.48 |
| Max. Negotiated Rate |
$270.86 |
| Rate for Payer: Aetna Commercial |
$255.82
|
| Rate for Payer: Aetna Medicare |
$78.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$94.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$94.05
|
| Rate for Payer: BCBS Complete |
$120.38
|
| Rate for Payer: BCBS MAPPO |
$75.24
|
| Rate for Payer: BCBS Trust/PPO |
$247.42
|
| Rate for Payer: BCN Commercial |
$234.00
|
| Rate for Payer: BCN Medicare Advantage |
$75.24
|
| Rate for Payer: Cash Price |
$240.77
|
| Rate for Payer: Cofinity Commercial |
$258.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.77
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$75.24
|
| Rate for Payer: Healthscope Commercial |
$270.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.72
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$79.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$86.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.82
|
| Rate for Payer: Nomi Health Commercial |
$246.79
|
| Rate for Payer: PACE Senior Care Partners |
$71.48
|
| Rate for Payer: PACE SWMI |
$75.24
|
| Rate for Payer: PHP Commercial |
$255.82
|
| Rate for Payer: PHP Medicare Advantage |
$75.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.62
|
| Rate for Payer: Priority Health HMO/PPO |
$261.84
|
| Rate for Payer: Priority Health Medicare |
$75.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$201.64
|
| Rate for Payer: Railroad Medicare Medicare |
$75.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$264.84
|
| Rate for Payer: UHC Core |
$251.30
|
| Rate for Payer: UHC Dual Complete DSNP |
$75.24
|
| Rate for Payer: UHC Exchange |
$75.24
|
| Rate for Payer: UHC Medicare Advantage |
$75.24
|
| Rate for Payer: VA VA |
$75.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.72
|
|
|
HYOSCYAMINE 0.125 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$300.96
|
|
|
Service Code
|
NDC 43199001201
|
| Hospital Charge Code |
29822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.62 |
| Max. Negotiated Rate |
$270.86 |
| Rate for Payer: Aetna Commercial |
$255.82
|
| Rate for Payer: BCBS Trust/PPO |
$245.67
|
| Rate for Payer: BCN Commercial |
$232.58
|
| Rate for Payer: Cash Price |
$240.77
|
| Rate for Payer: Cofinity Commercial |
$258.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.77
|
| Rate for Payer: Healthscope Commercial |
$270.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.82
|
| Rate for Payer: Nomi Health Commercial |
$246.79
|
| Rate for Payer: PHP Commercial |
$255.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.62
|
| Rate for Payer: Priority Health HMO/PPO |
$261.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$201.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$264.84
|
| Rate for Payer: UHC Core |
$251.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.72
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$303.36
|
|
|
Service Code
|
NDC 47781001101
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.05 |
| Max. Negotiated Rate |
$273.02 |
| Rate for Payer: Aetna Commercial |
$257.86
|
| Rate for Payer: Aetna Medicare |
$78.87
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$94.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$94.80
|
| Rate for Payer: BCBS Complete |
$121.34
|
| Rate for Payer: BCBS MAPPO |
$75.84
|
| Rate for Payer: BCBS Trust/PPO |
$249.39
|
| Rate for Payer: BCN Commercial |
$235.86
|
| Rate for Payer: BCN Medicare Advantage |
$75.84
|
| Rate for Payer: Cash Price |
$242.69
|
| Rate for Payer: Cofinity Commercial |
$260.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$242.69
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$75.84
|
| Rate for Payer: Healthscope Commercial |
$273.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$227.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$79.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$87.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$257.86
|
| Rate for Payer: Nomi Health Commercial |
$248.76
|
| Rate for Payer: PACE Senior Care Partners |
$72.05
|
| Rate for Payer: PACE SWMI |
$75.84
|
| Rate for Payer: PHP Commercial |
$257.86
|
| Rate for Payer: PHP Medicare Advantage |
$75.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.18
|
| Rate for Payer: Priority Health HMO/PPO |
$263.92
|
| Rate for Payer: Priority Health Medicare |
$76.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$203.25
|
| Rate for Payer: Railroad Medicare Medicare |
$75.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$266.96
|
| Rate for Payer: UHC Core |
$253.31
|
| Rate for Payer: UHC Dual Complete DSNP |
$75.84
|
| Rate for Payer: UHC Exchange |
$75.84
|
| Rate for Payer: UHC Medicare Advantage |
$75.84
|
| Rate for Payer: VA VA |
$75.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$227.52
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$357.20
|
|
|
Service Code
|
NDC 62559042401
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.83 |
| Max. Negotiated Rate |
$321.48 |
| Rate for Payer: Aetna Commercial |
$303.62
|
| Rate for Payer: Aetna Medicare |
$92.87
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$111.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$111.62
|
| Rate for Payer: BCBS Complete |
$142.88
|
| Rate for Payer: BCBS MAPPO |
$89.30
|
| Rate for Payer: BCBS Trust/PPO |
$293.65
|
| Rate for Payer: BCN Commercial |
$277.72
|
| Rate for Payer: BCN Medicare Advantage |
$89.30
|
| Rate for Payer: Cash Price |
$285.76
|
| Rate for Payer: Cofinity Commercial |
$307.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$89.30
|
| Rate for Payer: Healthscope Commercial |
$321.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$93.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$102.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$303.62
|
| Rate for Payer: Nomi Health Commercial |
$292.90
|
| Rate for Payer: PACE Senior Care Partners |
$84.83
|
| Rate for Payer: PACE SWMI |
$89.30
|
| Rate for Payer: PHP Commercial |
$303.62
|
| Rate for Payer: PHP Medicare Advantage |
$89.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.18
|
| Rate for Payer: Priority Health HMO/PPO |
$310.76
|
| Rate for Payer: Priority Health Medicare |
$90.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$239.32
|
| Rate for Payer: Railroad Medicare Medicare |
$89.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$314.34
|
| Rate for Payer: UHC Core |
$298.26
|
| Rate for Payer: UHC Dual Complete DSNP |
$89.30
|
| Rate for Payer: UHC Exchange |
$89.30
|
| Rate for Payer: UHC Medicare Advantage |
$89.30
|
| Rate for Payer: VA VA |
$89.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.90
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$357.20
|
|
|
Service Code
|
NDC 62559042401
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$232.18 |
| Max. Negotiated Rate |
$321.48 |
| Rate for Payer: Aetna Commercial |
$303.62
|
| Rate for Payer: BCBS Trust/PPO |
$291.58
|
| Rate for Payer: BCN Commercial |
$276.04
|
| Rate for Payer: Cash Price |
$285.76
|
| Rate for Payer: Cofinity Commercial |
$307.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.76
|
| Rate for Payer: Healthscope Commercial |
$321.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$303.62
|
| Rate for Payer: Nomi Health Commercial |
$292.90
|
| Rate for Payer: PHP Commercial |
$303.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.18
|
| Rate for Payer: Priority Health HMO/PPO |
$310.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$239.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$314.34
|
| Rate for Payer: UHC Core |
$298.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.90
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$303.36
|
|
|
Service Code
|
NDC 47781001101
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.18 |
| Max. Negotiated Rate |
$273.02 |
| Rate for Payer: Aetna Commercial |
$257.86
|
| Rate for Payer: BCBS Trust/PPO |
$247.63
|
| Rate for Payer: BCN Commercial |
$234.44
|
| Rate for Payer: Cash Price |
$242.69
|
| Rate for Payer: Cofinity Commercial |
$260.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$242.69
|
| Rate for Payer: Healthscope Commercial |
$273.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$227.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$257.86
|
| Rate for Payer: Nomi Health Commercial |
$248.76
|
| Rate for Payer: PHP Commercial |
$257.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.18
|
| Rate for Payer: Priority Health HMO/PPO |
$263.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$203.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$266.96
|
| Rate for Payer: UHC Core |
$253.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$227.52
|
|
|
HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$2,413.90
|
|
|
Service Code
|
CPT 58555
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,298.80 |
| Max. Negotiated Rate |
$2,413.90 |
| Rate for Payer: BCBS Complete |
$2,413.90
|
| Rate for Payer: Mclaren Medicaid |
$2,298.80
|
| Rate for Payer: Meridian Medicaid |
$2,413.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,298.80
|
| Rate for Payer: UHCCP Medicaid |
$2,298.80
|
|
|
HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)
|
Facility
|
OP
|
$3,747.75
|
|
|
Service Code
|
CPT 58563
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,569.05 |
| Max. Negotiated Rate |
$3,747.75 |
| Rate for Payer: BCBS Complete |
$3,747.75
|
| Rate for Payer: Mclaren Medicaid |
$3,569.05
|
| Rate for Payer: Meridian Medicaid |
$3,747.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,569.05
|
| Rate for Payer: UHCCP Medicaid |
$3,569.05
|
|
|
HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY
|
Facility
|
OP
|
$2,413.90
|
|
|
Service Code
|
CPT 58562
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,298.80 |
| Max. Negotiated Rate |
$2,413.90 |
| Rate for Payer: BCBS Complete |
$2,413.90
|
| Rate for Payer: Mclaren Medicaid |
$2,298.80
|
| Rate for Payer: Meridian Medicaid |
$2,413.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,298.80
|
| Rate for Payer: UHCCP Medicaid |
$2,298.80
|
|
|
HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA
|
Facility
|
OP
|
$3,747.75
|
|
|
Service Code
|
CPT 58561
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,569.05 |
| Max. Negotiated Rate |
$3,747.75 |
| Rate for Payer: BCBS Complete |
$3,747.75
|
| Rate for Payer: Mclaren Medicaid |
$3,569.05
|
| Rate for Payer: Meridian Medicaid |
$3,747.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,569.05
|
| Rate for Payer: UHCCP Medicaid |
$3,569.05
|
|
|
HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C
|
Facility
|
OP
|
$2,413.90
|
|
|
Service Code
|
CPT 58558
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,298.80 |
| Max. Negotiated Rate |
$2,413.90 |
| Rate for Payer: BCBS Complete |
$2,413.90
|
| Rate for Payer: Mclaren Medicaid |
$2,298.80
|
| Rate for Payer: Meridian Medicaid |
$2,413.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,298.80
|
| Rate for Payer: UHCCP Medicaid |
$2,298.80
|
|
