|
HYDROXYUREA 500 MG CAPSULE
|
Facility
|
OP
|
$348.96
|
|
|
Service Code
|
NDC 00904693961
|
| Hospital Charge Code |
10236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.12 |
| Max. Negotiated Rate |
$314.06 |
| Rate for Payer: Aetna American Axle |
$226.82
|
| Rate for Payer: Aetna Commercial |
$296.62
|
| Rate for Payer: Aetna Medicare |
$174.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$226.82
|
| Rate for Payer: BCBS Complete |
$139.58
|
| Rate for Payer: Cash Price |
$279.17
|
| Rate for Payer: Cofinity Commercial |
$244.27
|
| Rate for Payer: Cofinity Commercial |
$300.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$244.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$279.17
|
| Rate for Payer: Healthscope Commercial |
$314.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$244.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$261.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$296.62
|
| Rate for Payer: PHP Commercial |
$296.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$226.82
|
| Rate for Payer: Priority Health SBD |
$219.84
|
| Rate for Payer: UMR Bronson Commercial |
$129.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$261.72
|
|
|
HYDROXYUREA 500 MG CAPSULE
|
Facility
|
OP
|
$250.08
|
|
|
Service Code
|
NDC 49884072401
|
| Hospital Charge Code |
10236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.53 |
| Max. Negotiated Rate |
$225.07 |
| Rate for Payer: Aetna American Axle |
$162.55
|
| Rate for Payer: Aetna Commercial |
$212.57
|
| Rate for Payer: Aetna Medicare |
$125.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.55
|
| Rate for Payer: BCBS Complete |
$100.03
|
| Rate for Payer: Cash Price |
$200.06
|
| Rate for Payer: Cofinity Commercial |
$175.06
|
| Rate for Payer: Cofinity Commercial |
$215.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$175.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.06
|
| Rate for Payer: Healthscope Commercial |
$225.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.57
|
| Rate for Payer: PHP Commercial |
$212.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.55
|
| Rate for Payer: Priority Health SBD |
$157.55
|
| Rate for Payer: UMR Bronson Commercial |
$92.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.56
|
|
|
HYDROXYUREA 500 MG CAPSULE
|
Facility
|
IP
|
$348.96
|
|
|
Service Code
|
NDC 00904693961
|
| Hospital Charge Code |
10236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.54 |
| Max. Negotiated Rate |
$314.06 |
| Rate for Payer: Aetna American Axle |
$226.82
|
| Rate for Payer: Aetna Commercial |
$296.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$226.82
|
| Rate for Payer: Cash Price |
$279.17
|
| Rate for Payer: Cofinity Commercial |
$244.27
|
| Rate for Payer: Cofinity Commercial |
$300.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$244.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$279.17
|
| Rate for Payer: Healthscope Commercial |
$314.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$244.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$261.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$296.62
|
| Rate for Payer: PHP Commercial |
$296.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$226.82
|
| Rate for Payer: Priority Health SBD |
$219.84
|
| Rate for Payer: UMR Bronson Commercial |
$153.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$261.72
|
|
|
HYDROXYUREA 500 MG CAPSULE
|
Facility
|
OP
|
$250.08
|
|
|
Service Code
|
NDC 69315016401
|
| Hospital Charge Code |
10236
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.53 |
| Max. Negotiated Rate |
$225.07 |
| Rate for Payer: Aetna American Axle |
$162.55
|
| Rate for Payer: Aetna Commercial |
$212.57
|
| Rate for Payer: Aetna Medicare |
$125.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.55
|
| Rate for Payer: BCBS Complete |
$100.03
|
| Rate for Payer: Cash Price |
$200.06
|
| Rate for Payer: Cofinity Commercial |
$175.06
|
| Rate for Payer: Cofinity Commercial |
$215.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$175.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.06
|
| Rate for Payer: Healthscope Commercial |
$225.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.57
|
| Rate for Payer: PHP Commercial |
$212.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.55
|
| Rate for Payer: Priority Health SBD |
$157.55
|
| Rate for Payer: UMR Bronson Commercial |
$92.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.56
|
|
|
HYDROXYUREA (BULK) 100 % POWDER
|
Facility
|
IP
|
$1,272.00
|
|
|
Service Code
|
NDC 51552085104
|
| Hospital Charge Code |
23979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$559.68 |
| Max. Negotiated Rate |
$1,144.80 |
| Rate for Payer: Aetna American Axle |
$826.80
|
| Rate for Payer: Aetna Commercial |
$1,081.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$826.80
|
| Rate for Payer: Cash Price |
$1,017.60
|
| Rate for Payer: Cofinity Commercial |
$1,093.92
|
| Rate for Payer: Cofinity Commercial |
$890.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$890.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,017.60
|
| Rate for Payer: Healthscope Commercial |
$1,144.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$890.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$954.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,081.20
|
| Rate for Payer: PHP Commercial |
$1,081.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$826.80
|
| Rate for Payer: Priority Health SBD |
$801.36
|
| Rate for Payer: UMR Bronson Commercial |
$559.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$954.00
|
|
|
HYDROXYUREA (BULK) 100 % POWDER
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
NDC 51552085109
|
| Hospital Charge Code |
23979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.20 |
| Max. Negotiated Rate |
$297.00 |
| Rate for Payer: Aetna American Axle |
$214.50
|
| Rate for Payer: Aetna Commercial |
$280.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$214.50
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cofinity Commercial |
$231.00
|
| Rate for Payer: Cofinity Commercial |
$283.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$231.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.00
|
| Rate for Payer: Healthscope Commercial |
$297.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$247.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$280.50
|
| Rate for Payer: PHP Commercial |
$280.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.50
|
| Rate for Payer: Priority Health SBD |
$207.90
|
| Rate for Payer: UMR Bronson Commercial |
$145.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$247.50
|
|
|
HYDROXYUREA (BULK) 100 % POWDER
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
NDC 51552085109
|
| Hospital Charge Code |
23979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.10 |
| Max. Negotiated Rate |
$297.00 |
| Rate for Payer: Aetna American Axle |
$214.50
|
| Rate for Payer: Aetna Commercial |
$280.50
|
| Rate for Payer: Aetna Medicare |
$165.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$214.50
|
| Rate for Payer: BCBS Complete |
$132.00
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cofinity Commercial |
$231.00
|
| Rate for Payer: Cofinity Commercial |
$283.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$231.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.00
|
| Rate for Payer: Healthscope Commercial |
$297.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$247.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$280.50
|
| Rate for Payer: PHP Commercial |
$280.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.50
|
| Rate for Payer: Priority Health SBD |
$207.90
|
| Rate for Payer: UMR Bronson Commercial |
$122.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$247.50
|
|
|
HYDROXYUREA (BULK) 100 % POWDER
|
Facility
|
OP
|
$1,272.00
|
|
|
Service Code
|
NDC 51552085104
|
| Hospital Charge Code |
23979
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$470.64 |
| Max. Negotiated Rate |
$1,144.80 |
| Rate for Payer: Aetna American Axle |
$826.80
|
| Rate for Payer: Aetna Commercial |
$1,081.20
|
| Rate for Payer: Aetna Medicare |
$636.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$826.80
|
| Rate for Payer: BCBS Complete |
$508.80
|
| Rate for Payer: Cash Price |
$1,017.60
|
| Rate for Payer: Cofinity Commercial |
$1,093.92
|
| Rate for Payer: Cofinity Commercial |
$890.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$890.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,017.60
|
| Rate for Payer: Healthscope Commercial |
$1,144.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$890.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$954.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,081.20
|
| Rate for Payer: PHP Commercial |
$1,081.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$826.80
|
| Rate for Payer: Priority Health SBD |
$801.36
|
| Rate for Payer: UMR Bronson Commercial |
$470.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$954.00
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$1,478.37
|
|
|
Service Code
|
NDC 54838050280
|
| Hospital Charge Code |
3771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$547.00 |
| Max. Negotiated Rate |
$1,330.53 |
| Rate for Payer: Aetna American Axle |
$960.94
|
| Rate for Payer: Aetna Commercial |
$1,256.61
|
| Rate for Payer: Aetna Medicare |
$739.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$960.94
|
| Rate for Payer: BCBS Complete |
$591.35
|
| Rate for Payer: Cash Price |
$1,182.70
|
| Rate for Payer: Cofinity Commercial |
$1,034.86
|
| Rate for Payer: Cofinity Commercial |
$1,271.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,034.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,182.70
|
| Rate for Payer: Healthscope Commercial |
$1,330.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,034.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,108.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,256.61
|
| Rate for Payer: PHP Commercial |
$1,256.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$960.94
|
| Rate for Payer: Priority Health SBD |
$931.37
|
| Rate for Payer: UMR Bronson Commercial |
$547.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,108.78
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$236.88
|
|
|
Service Code
|
NDC 60432015004
|
| Hospital Charge Code |
3771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.65 |
| Max. Negotiated Rate |
$213.19 |
| Rate for Payer: Aetna American Axle |
$153.97
|
| Rate for Payer: Aetna Commercial |
$201.35
|
| Rate for Payer: Aetna Medicare |
$118.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.97
|
| Rate for Payer: BCBS Complete |
$94.75
|
| Rate for Payer: Cash Price |
$189.50
|
| Rate for Payer: Cofinity Commercial |
$165.82
|
| Rate for Payer: Cofinity Commercial |
$203.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$165.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$189.50
|
| Rate for Payer: Healthscope Commercial |
$213.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$165.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$177.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$201.35
|
| Rate for Payer: PHP Commercial |
$201.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.97
|
| Rate for Payer: Priority Health SBD |
$149.23
|
| Rate for Payer: UMR Bronson Commercial |
$87.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$177.66
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,478.37
|
|
|
Service Code
|
NDC 54838050280
|
| Hospital Charge Code |
3771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$650.48 |
| Max. Negotiated Rate |
$1,330.53 |
| Rate for Payer: Aetna American Axle |
$960.94
|
| Rate for Payer: Aetna Commercial |
$1,256.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$960.94
|
| Rate for Payer: Cash Price |
$1,182.70
|
| Rate for Payer: Cofinity Commercial |
$1,034.86
|
| Rate for Payer: Cofinity Commercial |
$1,271.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,034.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,182.70
|
| Rate for Payer: Healthscope Commercial |
$1,330.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,034.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,108.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,256.61
|
| Rate for Payer: PHP Commercial |
$1,256.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$960.94
|
| Rate for Payer: Priority Health SBD |
$931.37
|
| Rate for Payer: UMR Bronson Commercial |
$650.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,108.78
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$277.89
|
|
|
Service Code
|
NDC 60432015016
|
| Hospital Charge Code |
3771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.82 |
| Max. Negotiated Rate |
$250.10 |
| Rate for Payer: Aetna American Axle |
$180.63
|
| Rate for Payer: Aetna Commercial |
$236.21
|
| Rate for Payer: Aetna Medicare |
$138.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.63
|
| Rate for Payer: BCBS Complete |
$111.16
|
| Rate for Payer: Cash Price |
$222.31
|
| Rate for Payer: Cofinity Commercial |
$194.52
|
| Rate for Payer: Cofinity Commercial |
$238.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$194.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.31
|
| Rate for Payer: Healthscope Commercial |
$250.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$236.21
|
| Rate for Payer: PHP Commercial |
$236.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.63
|
| Rate for Payer: Priority Health SBD |
$175.07
|
| Rate for Payer: UMR Bronson Commercial |
$102.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.42
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$236.88
|
|
|
Service Code
|
NDC 60432015004
|
| Hospital Charge Code |
3771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.23 |
| Max. Negotiated Rate |
$213.19 |
| Rate for Payer: Aetna American Axle |
$153.97
|
| Rate for Payer: Aetna Commercial |
$201.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.97
|
| Rate for Payer: Cash Price |
$189.50
|
| Rate for Payer: Cofinity Commercial |
$165.82
|
| Rate for Payer: Cofinity Commercial |
$203.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$165.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$189.50
|
| Rate for Payer: Healthscope Commercial |
$213.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$165.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$177.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$201.35
|
| Rate for Payer: PHP Commercial |
$201.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.97
|
| Rate for Payer: Priority Health SBD |
$149.23
|
| Rate for Payer: UMR Bronson Commercial |
$104.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$177.66
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$277.89
|
|
|
Service Code
|
NDC 60432015016
|
| Hospital Charge Code |
3771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.27 |
| Max. Negotiated Rate |
$250.10 |
| Rate for Payer: Aetna American Axle |
$180.63
|
| Rate for Payer: Aetna Commercial |
$236.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.63
|
| Rate for Payer: Cash Price |
$222.31
|
| Rate for Payer: Cofinity Commercial |
$194.52
|
| Rate for Payer: Cofinity Commercial |
$238.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$194.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.31
|
| Rate for Payer: Healthscope Commercial |
$250.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$236.21
|
| Rate for Payer: PHP Commercial |
$236.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.63
|
| Rate for Payer: Priority Health SBD |
$175.07
|
| Rate for Payer: UMR Bronson Commercial |
$122.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.42
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
IP
|
$98.70
|
|
|
Service Code
|
NDC 23155050001
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.43 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna American Axle |
$64.16
|
| Rate for Payer: Aetna Commercial |
$83.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.16
|
| Rate for Payer: Cash Price |
$78.96
|
| Rate for Payer: Cofinity Commercial |
$69.09
|
| Rate for Payer: Cofinity Commercial |
$84.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$69.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.96
|
| Rate for Payer: Healthscope Commercial |
$88.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.90
|
| Rate for Payer: PHP Commercial |
$83.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.16
|
| Rate for Payer: Priority Health SBD |
$62.18
|
| Rate for Payer: UMR Bronson Commercial |
$43.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.02
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
OP
|
$427.70
|
|
|
Service Code
|
NDC 68084025311
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.25 |
| Max. Negotiated Rate |
$384.93 |
| Rate for Payer: Aetna American Axle |
$278.00
|
| Rate for Payer: Aetna Commercial |
$363.54
|
| Rate for Payer: Aetna Medicare |
$213.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.00
|
| Rate for Payer: BCBS Complete |
$171.08
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$299.39
|
| Rate for Payer: Cofinity Commercial |
$367.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$299.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Healthscope Commercial |
$384.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$320.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$363.54
|
| Rate for Payer: PHP Commercial |
$363.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.00
|
| Rate for Payer: Priority Health SBD |
$269.45
|
| Rate for Payer: UMR Bronson Commercial |
$158.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$320.78
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
IP
|
$427.70
|
|
|
Service Code
|
NDC 68084025301
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.19 |
| Max. Negotiated Rate |
$384.93 |
| Rate for Payer: Aetna American Axle |
$278.00
|
| Rate for Payer: Aetna Commercial |
$363.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.00
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$299.39
|
| Rate for Payer: Cofinity Commercial |
$367.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$299.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Healthscope Commercial |
$384.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$320.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$363.54
|
| Rate for Payer: PHP Commercial |
$363.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.00
|
| Rate for Payer: Priority Health SBD |
$269.45
|
| Rate for Payer: UMR Bronson Commercial |
$188.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$320.78
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
OP
|
$427.70
|
|
|
Service Code
|
NDC 68084025301
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.25 |
| Max. Negotiated Rate |
$384.93 |
| Rate for Payer: Aetna American Axle |
$278.00
|
| Rate for Payer: Aetna Commercial |
$363.54
|
| Rate for Payer: Aetna Medicare |
$213.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.00
|
| Rate for Payer: BCBS Complete |
$171.08
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$299.39
|
| Rate for Payer: Cofinity Commercial |
$367.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$299.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Healthscope Commercial |
$384.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$320.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$363.54
|
| Rate for Payer: PHP Commercial |
$363.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.00
|
| Rate for Payer: Priority Health SBD |
$269.45
|
| Rate for Payer: UMR Bronson Commercial |
$158.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$320.78
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
OP
|
$98.70
|
|
|
Service Code
|
NDC 23155050001
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.52 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna American Axle |
$64.16
|
| Rate for Payer: Aetna Commercial |
$83.90
|
| Rate for Payer: Aetna Medicare |
$49.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.16
|
| Rate for Payer: BCBS Complete |
$39.48
|
| Rate for Payer: Cash Price |
$78.96
|
| Rate for Payer: Cofinity Commercial |
$69.09
|
| Rate for Payer: Cofinity Commercial |
$84.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$69.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.96
|
| Rate for Payer: Healthscope Commercial |
$88.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.90
|
| Rate for Payer: PHP Commercial |
$83.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.16
|
| Rate for Payer: Priority Health SBD |
$62.18
|
| Rate for Payer: UMR Bronson Commercial |
$36.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.02
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
IP
|
$427.70
|
|
|
Service Code
|
NDC 68084025311
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.19 |
| Max. Negotiated Rate |
$384.93 |
| Rate for Payer: Aetna American Axle |
$278.00
|
| Rate for Payer: Aetna Commercial |
$363.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.00
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$299.39
|
| Rate for Payer: Cofinity Commercial |
$367.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$299.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Healthscope Commercial |
$384.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$320.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$363.54
|
| Rate for Payer: PHP Commercial |
$363.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.00
|
| Rate for Payer: Priority Health SBD |
$269.45
|
| Rate for Payer: UMR Bronson Commercial |
$188.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$320.78
|
|
|
HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$69.57
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
3769
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.74 |
| Max. Negotiated Rate |
$62.61 |
| Rate for Payer: Aetna American Axle |
$45.22
|
| Rate for Payer: Aetna Commercial |
$59.13
|
| Rate for Payer: Aetna Medicare |
$34.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.22
|
| Rate for Payer: BCBS Complete |
$27.83
|
| Rate for Payer: BCBS Trust/PPO |
$33.42
|
| Rate for Payer: BCN Commercial |
$33.42
|
| Rate for Payer: Cash Price |
$55.66
|
| Rate for Payer: Cash Price |
$55.66
|
| Rate for Payer: Cofinity Commercial |
$48.70
|
| Rate for Payer: Cofinity Commercial |
$59.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.66
|
| Rate for Payer: Healthscope Commercial |
$62.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.13
|
| Rate for Payer: PHP Commercial |
$59.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.22
|
| Rate for Payer: Priority Health SBD |
$43.83
|
| Rate for Payer: UMR Bronson Commercial |
$25.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.18
|
|
|
HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$69.57
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
3769
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.61 |
| Max. Negotiated Rate |
$62.61 |
| Rate for Payer: Aetna American Axle |
$45.22
|
| Rate for Payer: Aetna Commercial |
$59.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.22
|
| Rate for Payer: Cash Price |
$55.66
|
| Rate for Payer: Cofinity Commercial |
$48.70
|
| Rate for Payer: Cofinity Commercial |
$59.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.66
|
| Rate for Payer: Healthscope Commercial |
$62.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.13
|
| Rate for Payer: PHP Commercial |
$59.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.22
|
| Rate for Payer: Priority Health SBD |
$43.83
|
| Rate for Payer: UMR Bronson Commercial |
$30.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.18
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
OP
|
$441.80
|
|
|
Service Code
|
NDC 63739048610
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.47 |
| Max. Negotiated Rate |
$397.62 |
| Rate for Payer: Aetna American Axle |
$287.17
|
| Rate for Payer: Aetna Commercial |
$375.53
|
| Rate for Payer: Aetna Medicare |
$220.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.17
|
| Rate for Payer: BCBS Complete |
$176.72
|
| Rate for Payer: Cash Price |
$353.44
|
| Rate for Payer: Cofinity Commercial |
$309.26
|
| Rate for Payer: Cofinity Commercial |
$379.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$309.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.44
|
| Rate for Payer: Healthscope Commercial |
$397.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$309.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$331.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$375.53
|
| Rate for Payer: PHP Commercial |
$375.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.17
|
| Rate for Payer: Priority Health SBD |
$278.33
|
| Rate for Payer: UMR Bronson Commercial |
$163.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$331.35
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
IP
|
$441.80
|
|
|
Service Code
|
NDC 63739048610
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.39 |
| Max. Negotiated Rate |
$397.62 |
| Rate for Payer: Aetna American Axle |
$287.17
|
| Rate for Payer: Aetna Commercial |
$375.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.17
|
| Rate for Payer: Cash Price |
$353.44
|
| Rate for Payer: Cofinity Commercial |
$309.26
|
| Rate for Payer: Cofinity Commercial |
$379.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$309.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.44
|
| Rate for Payer: Healthscope Commercial |
$397.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$309.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$331.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$375.53
|
| Rate for Payer: PHP Commercial |
$375.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.17
|
| Rate for Payer: Priority Health SBD |
$278.33
|
| Rate for Payer: UMR Bronson Commercial |
$194.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$331.35
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
OP
|
$2.82
|
|
|
Service Code
|
NDC 68084025411
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna American Axle |
$1.83
|
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: Aetna Medicare |
$1.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: BCBS Complete |
$1.13
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.26
|
| Rate for Payer: Healthscope Commercial |
$2.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.40
|
| Rate for Payer: PHP Commercial |
$2.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health SBD |
$1.78
|
| Rate for Payer: UMR Bronson Commercial |
$1.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.12
|
|
