|
HYDRALAZINE 25 MG TABLET
|
Facility
|
IP
|
$258.50
|
|
|
Service Code
|
NDC 00904644161
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.03 |
| Max. Negotiated Rate |
$258.50 |
| Rate for Payer: Aetna Commercial |
$232.65
|
| Rate for Payer: ASR ASR |
$250.75
|
| Rate for Payer: ASR Commercial |
$250.75
|
| Rate for Payer: BCBS Trust/PPO |
$210.65
|
| Rate for Payer: BCN Commercial |
$200.42
|
| Rate for Payer: Cash Price |
$206.80
|
| Rate for Payer: Cofinity Commercial |
$242.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.80
|
| Rate for Payer: Healthscope Commercial |
$258.50
|
| Rate for Payer: Healthscope Whirlpool |
$250.75
|
| Rate for Payer: Mclaren Commercial |
$232.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.72
|
| Rate for Payer: Nomi Health Commercial |
$211.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$227.48
|
|
|
HYDRALAZINE 25 MG TABLET
|
Facility
|
OP
|
$82.25
|
|
|
Service Code
|
NDC 23155083301
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$74.03
|
| Rate for Payer: Aetna Medicare |
$41.12
|
| Rate for Payer: ASR ASR |
$79.78
|
| Rate for Payer: ASR Commercial |
$79.78
|
| Rate for Payer: BCBS Complete |
$32.90
|
| Rate for Payer: BCBS Trust/PPO |
$67.35
|
| Rate for Payer: BCN Commercial |
$63.77
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$77.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Healthscope Whirlpool |
$79.78
|
| Rate for Payer: Mclaren Commercial |
$74.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.91
|
| Rate for Payer: Nomi Health Commercial |
$67.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$72.07
|
| Rate for Payer: Priority Health Narrow Network |
$57.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.38
|
|
|
HYDRALAZINE 25 MG TABLET
|
Facility
|
IP
|
$82.25
|
|
|
Service Code
|
NDC 23155083301
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.46 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$74.03
|
| Rate for Payer: ASR ASR |
$79.78
|
| Rate for Payer: ASR Commercial |
$79.78
|
| Rate for Payer: BCBS Trust/PPO |
$67.03
|
| Rate for Payer: BCN Commercial |
$63.77
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$77.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Healthscope Whirlpool |
$79.78
|
| Rate for Payer: Mclaren Commercial |
$74.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.91
|
| Rate for Payer: Nomi Health Commercial |
$67.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.38
|
|
|
HYDRALAZINE 25 MG TABLET
|
Facility
|
IP
|
$3.74
|
|
|
Service Code
|
NDC 62584073311
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: ASR ASR |
$3.63
|
| Rate for Payer: ASR Commercial |
$3.63
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCN Commercial |
$2.90
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$3.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.74
|
| Rate for Payer: Healthscope Whirlpool |
$3.63
|
| Rate for Payer: Mclaren Commercial |
$3.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: Nomi Health Commercial |
$3.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.29
|
|
|
HYDRALAZINE 25 MG TABLET
|
Facility
|
OP
|
$425.35
|
|
|
Service Code
|
NDC 51079007520
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.14 |
| Max. Negotiated Rate |
$425.35 |
| Rate for Payer: Aetna Commercial |
$382.81
|
| Rate for Payer: Aetna Medicare |
$212.68
|
| Rate for Payer: ASR ASR |
$412.59
|
| Rate for Payer: ASR Commercial |
$412.59
|
| Rate for Payer: BCBS Complete |
$170.14
|
| Rate for Payer: BCBS Trust/PPO |
$348.32
|
| Rate for Payer: BCN Commercial |
$329.77
|
| Rate for Payer: Cash Price |
$340.28
|
| Rate for Payer: Cofinity Commercial |
$399.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.28
|
| Rate for Payer: Healthscope Commercial |
$425.35
|
| Rate for Payer: Healthscope Whirlpool |
$412.59
|
| Rate for Payer: Mclaren Commercial |
$382.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.55
|
| Rate for Payer: Nomi Health Commercial |
$348.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$372.69
|
| Rate for Payer: Priority Health Narrow Network |
$298.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$374.31
|
|
|
HYDRALAZINE 25 MG TABLET
|
Facility
|
OP
|
$4.25
|
|
|
Service Code
|
NDC 51079007501
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Aetna Medicare |
$2.12
|
| Rate for Payer: ASR ASR |
$4.12
|
| Rate for Payer: ASR Commercial |
$4.12
|
| Rate for Payer: BCBS Complete |
$1.70
|
| Rate for Payer: BCBS Trust/PPO |
$3.48
|
| Rate for Payer: BCN Commercial |
$3.30
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: Cofinity Commercial |
$4.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.40
|
| Rate for Payer: Healthscope Commercial |
$4.25
|
| Rate for Payer: Healthscope Whirlpool |
$4.12
|
| Rate for Payer: Mclaren Commercial |
$3.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.61
|
| Rate for Payer: Nomi Health Commercial |
$3.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.72
|
| Rate for Payer: Priority Health Narrow Network |
$2.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.74
|
|
|
HYDRALAZINE 25 MG TABLET
|
Facility
|
OP
|
$3.74
|
|
|
Service Code
|
NDC 62584073311
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Aetna Medicare |
$1.87
|
| Rate for Payer: ASR ASR |
$3.63
|
| Rate for Payer: ASR Commercial |
$3.63
|
| Rate for Payer: BCBS Complete |
$1.50
|
| Rate for Payer: BCBS Trust/PPO |
$3.06
|
| Rate for Payer: BCN Commercial |
$2.90
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$3.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.74
|
| Rate for Payer: Healthscope Whirlpool |
$3.63
|
| Rate for Payer: Mclaren Commercial |
$3.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: Nomi Health Commercial |
$3.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.28
|
| Rate for Payer: Priority Health Narrow Network |
$2.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.29
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
OP
|
$4.37
|
|
|
Service Code
|
NDC 60687059311
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.93
|
| Rate for Payer: Aetna Medicare |
$2.19
|
| Rate for Payer: ASR ASR |
$4.24
|
| Rate for Payer: ASR Commercial |
$4.24
|
| Rate for Payer: BCBS Complete |
$1.75
|
| Rate for Payer: BCBS Trust/PPO |
$3.58
|
| Rate for Payer: BCN Commercial |
$3.39
|
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Cofinity Commercial |
$4.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.50
|
| Rate for Payer: Healthscope Commercial |
$4.37
|
| Rate for Payer: Healthscope Whirlpool |
$4.24
|
| Rate for Payer: Mclaren Commercial |
$3.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.71
|
| Rate for Payer: Nomi Health Commercial |
$3.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.83
|
| Rate for Payer: Priority Health Narrow Network |
$3.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.85
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
IP
|
$437.10
|
|
|
Service Code
|
NDC 60687059301
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$284.12 |
| Max. Negotiated Rate |
$437.10 |
| Rate for Payer: Aetna Commercial |
$393.39
|
| Rate for Payer: ASR ASR |
$423.99
|
| Rate for Payer: ASR Commercial |
$423.99
|
| Rate for Payer: BCBS Trust/PPO |
$356.19
|
| Rate for Payer: BCN Commercial |
$338.88
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Commercial |
$410.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$437.10
|
| Rate for Payer: Healthscope Whirlpool |
$423.99
|
| Rate for Payer: Mclaren Commercial |
$393.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: Nomi Health Commercial |
$358.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$384.65
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
IP
|
$4.37
|
|
|
Service Code
|
NDC 60687059311
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.93
|
| Rate for Payer: ASR ASR |
$4.24
|
| Rate for Payer: ASR Commercial |
$4.24
|
| Rate for Payer: BCBS Trust/PPO |
$3.56
|
| Rate for Payer: BCN Commercial |
$3.39
|
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Cofinity Commercial |
$4.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.50
|
| Rate for Payer: Healthscope Commercial |
$4.37
|
| Rate for Payer: Healthscope Whirlpool |
$4.24
|
| Rate for Payer: Mclaren Commercial |
$3.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.71
|
| Rate for Payer: Nomi Health Commercial |
$3.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.85
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
OP
|
$437.10
|
|
|
Service Code
|
NDC 60687059301
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.84 |
| Max. Negotiated Rate |
$437.10 |
| Rate for Payer: Aetna Commercial |
$393.39
|
| Rate for Payer: Aetna Medicare |
$218.55
|
| Rate for Payer: ASR ASR |
$423.99
|
| Rate for Payer: ASR Commercial |
$423.99
|
| Rate for Payer: BCBS Complete |
$174.84
|
| Rate for Payer: BCBS Trust/PPO |
$357.94
|
| Rate for Payer: BCN Commercial |
$338.88
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Commercial |
$410.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$437.10
|
| Rate for Payer: Healthscope Whirlpool |
$423.99
|
| Rate for Payer: Mclaren Commercial |
$393.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: Nomi Health Commercial |
$358.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$382.99
|
| Rate for Payer: Priority Health Narrow Network |
$306.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$384.65
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$5.42
|
|
|
Service Code
|
NDC 50268040211
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$5.42 |
| Rate for Payer: Aetna Commercial |
$4.88
|
| Rate for Payer: ASR ASR |
$5.26
|
| Rate for Payer: ASR Commercial |
$5.26
|
| Rate for Payer: BCBS Trust/PPO |
$4.42
|
| Rate for Payer: BCN Commercial |
$4.20
|
| Rate for Payer: Cash Price |
$4.34
|
| Rate for Payer: Cofinity Commercial |
$5.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.34
|
| Rate for Payer: Healthscope Commercial |
$5.42
|
| Rate for Payer: Healthscope Whirlpool |
$5.26
|
| Rate for Payer: Mclaren Commercial |
$4.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.61
|
| Rate for Payer: Nomi Health Commercial |
$4.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.77
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$271.25
|
|
|
Service Code
|
NDC 50268040215
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.31 |
| Max. Negotiated Rate |
$271.25 |
| Rate for Payer: Aetna Commercial |
$244.12
|
| Rate for Payer: ASR ASR |
$263.11
|
| Rate for Payer: ASR Commercial |
$263.11
|
| Rate for Payer: BCBS Trust/PPO |
$221.04
|
| Rate for Payer: BCN Commercial |
$210.30
|
| Rate for Payer: Cash Price |
$217.00
|
| Rate for Payer: Cofinity Commercial |
$254.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.00
|
| Rate for Payer: Healthscope Commercial |
$271.25
|
| Rate for Payer: Healthscope Whirlpool |
$263.11
|
| Rate for Payer: Mclaren Commercial |
$244.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.56
|
| Rate for Payer: Nomi Health Commercial |
$222.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$238.70
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$80.33
|
|
|
Service Code
|
NDC 00406012562
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.21 |
| Max. Negotiated Rate |
$80.33 |
| Rate for Payer: Aetna Commercial |
$72.30
|
| Rate for Payer: ASR ASR |
$77.92
|
| Rate for Payer: ASR Commercial |
$77.92
|
| Rate for Payer: BCBS Trust/PPO |
$65.46
|
| Rate for Payer: BCN Commercial |
$62.28
|
| Rate for Payer: Cash Price |
$64.26
|
| Rate for Payer: Cofinity Commercial |
$75.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.26
|
| Rate for Payer: Healthscope Commercial |
$80.33
|
| Rate for Payer: Healthscope Whirlpool |
$77.92
|
| Rate for Payer: Mclaren Commercial |
$72.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.28
|
| Rate for Payer: Nomi Health Commercial |
$65.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.69
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
OP
|
$271.25
|
|
|
Service Code
|
NDC 50268040215
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$271.25 |
| Rate for Payer: Aetna Commercial |
$244.12
|
| Rate for Payer: Aetna Medicare |
$135.62
|
| Rate for Payer: ASR ASR |
$263.11
|
| Rate for Payer: ASR Commercial |
$263.11
|
| Rate for Payer: BCBS Complete |
$108.50
|
| Rate for Payer: BCBS Trust/PPO |
$222.13
|
| Rate for Payer: BCN Commercial |
$210.30
|
| Rate for Payer: Cash Price |
$217.00
|
| Rate for Payer: Cofinity Commercial |
$254.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.00
|
| Rate for Payer: Healthscope Commercial |
$271.25
|
| Rate for Payer: Healthscope Whirlpool |
$263.11
|
| Rate for Payer: Mclaren Commercial |
$244.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.56
|
| Rate for Payer: Nomi Health Commercial |
$222.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$237.67
|
| Rate for Payer: Priority Health Narrow Network |
$190.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$238.70
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
OP
|
$5.42
|
|
|
Service Code
|
NDC 50268040211
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$5.42 |
| Rate for Payer: Aetna Commercial |
$4.88
|
| Rate for Payer: Aetna Medicare |
$2.71
|
| Rate for Payer: ASR ASR |
$5.26
|
| Rate for Payer: ASR Commercial |
$5.26
|
| Rate for Payer: BCBS Complete |
$2.17
|
| Rate for Payer: BCBS Trust/PPO |
$4.44
|
| Rate for Payer: BCN Commercial |
$4.20
|
| Rate for Payer: Cash Price |
$4.34
|
| Rate for Payer: Cofinity Commercial |
$5.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.34
|
| Rate for Payer: Healthscope Commercial |
$5.42
|
| Rate for Payer: Healthscope Whirlpool |
$5.26
|
| Rate for Payer: Mclaren Commercial |
$4.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.61
|
| Rate for Payer: Nomi Health Commercial |
$4.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.75
|
| Rate for Payer: Priority Health Narrow Network |
$3.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.77
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
OP
|
$80.33
|
|
|
Service Code
|
NDC 00406012562
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.13 |
| Max. Negotiated Rate |
$80.33 |
| Rate for Payer: Aetna Commercial |
$72.30
|
| Rate for Payer: Aetna Medicare |
$40.16
|
| Rate for Payer: ASR ASR |
$77.92
|
| Rate for Payer: ASR Commercial |
$77.92
|
| Rate for Payer: BCBS Complete |
$32.13
|
| Rate for Payer: BCBS Trust/PPO |
$65.78
|
| Rate for Payer: BCN Commercial |
$62.28
|
| Rate for Payer: Cash Price |
$64.26
|
| Rate for Payer: Cofinity Commercial |
$75.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.26
|
| Rate for Payer: Healthscope Commercial |
$80.33
|
| Rate for Payer: Healthscope Whirlpool |
$77.92
|
| Rate for Payer: Mclaren Commercial |
$72.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.28
|
| Rate for Payer: Nomi Health Commercial |
$65.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$70.39
|
| Rate for Payer: Priority Health Narrow Network |
$56.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.69
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$8.03
|
|
|
Service Code
|
NDC 00406012523
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$8.03 |
| Rate for Payer: Aetna Commercial |
$7.23
|
| Rate for Payer: ASR ASR |
$7.79
|
| Rate for Payer: ASR Commercial |
$7.79
|
| Rate for Payer: BCBS Trust/PPO |
$6.54
|
| Rate for Payer: BCN Commercial |
$6.23
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: Cofinity Commercial |
$7.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.42
|
| Rate for Payer: Healthscope Commercial |
$8.03
|
| Rate for Payer: Healthscope Whirlpool |
$7.79
|
| Rate for Payer: Mclaren Commercial |
$7.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.83
|
| Rate for Payer: Nomi Health Commercial |
$6.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.07
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
OP
|
$8.03
|
|
|
Service Code
|
NDC 00406012523
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$8.03 |
| Rate for Payer: Aetna Commercial |
$7.23
|
| Rate for Payer: Aetna Medicare |
$4.01
|
| Rate for Payer: ASR ASR |
$7.79
|
| Rate for Payer: ASR Commercial |
$7.79
|
| Rate for Payer: BCBS Complete |
$3.21
|
| Rate for Payer: BCBS Trust/PPO |
$6.58
|
| Rate for Payer: BCN Commercial |
$6.23
|
| Rate for Payer: Cash Price |
$6.43
|
| Rate for Payer: Cofinity Commercial |
$7.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.42
|
| Rate for Payer: Healthscope Commercial |
$8.03
|
| Rate for Payer: Healthscope Whirlpool |
$7.79
|
| Rate for Payer: Mclaren Commercial |
$7.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.83
|
| Rate for Payer: Nomi Health Commercial |
$6.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7.04
|
| Rate for Payer: Priority Health Narrow Network |
$5.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.07
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
OP
|
$195.12
|
|
|
Service Code
|
NDC 50268040115
|
| Hospital Charge Code |
34505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.05 |
| Max. Negotiated Rate |
$195.12 |
| Rate for Payer: Aetna Commercial |
$175.61
|
| Rate for Payer: Aetna Medicare |
$97.56
|
| Rate for Payer: ASR ASR |
$189.27
|
| Rate for Payer: ASR Commercial |
$189.27
|
| Rate for Payer: BCBS Complete |
$78.05
|
| Rate for Payer: BCBS Trust/PPO |
$159.78
|
| Rate for Payer: BCN Commercial |
$151.28
|
| Rate for Payer: Cash Price |
$156.10
|
| Rate for Payer: Cofinity Commercial |
$183.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.10
|
| Rate for Payer: Healthscope Commercial |
$195.12
|
| Rate for Payer: Healthscope Whirlpool |
$189.27
|
| Rate for Payer: Mclaren Commercial |
$175.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.85
|
| Rate for Payer: Nomi Health Commercial |
$160.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$170.96
|
| Rate for Payer: Priority Health Narrow Network |
$136.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$171.71
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$63.70
|
|
|
Service Code
|
NDC 00406012362
|
| Hospital Charge Code |
34505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.41 |
| Max. Negotiated Rate |
$63.70 |
| Rate for Payer: Aetna Commercial |
$57.33
|
| Rate for Payer: ASR ASR |
$61.79
|
| Rate for Payer: ASR Commercial |
$61.79
|
| Rate for Payer: BCBS Trust/PPO |
$51.91
|
| Rate for Payer: BCN Commercial |
$49.39
|
| Rate for Payer: Cash Price |
$50.96
|
| Rate for Payer: Cofinity Commercial |
$59.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.96
|
| Rate for Payer: Healthscope Commercial |
$63.70
|
| Rate for Payer: Healthscope Whirlpool |
$61.79
|
| Rate for Payer: Mclaren Commercial |
$57.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.15
|
| Rate for Payer: Nomi Health Commercial |
$52.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$56.06
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$8.63
|
|
|
Service Code
|
NDC 68084089511
|
| Hospital Charge Code |
34505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$8.63 |
| Rate for Payer: Aetna Commercial |
$7.77
|
| Rate for Payer: ASR ASR |
$8.37
|
| Rate for Payer: ASR Commercial |
$8.37
|
| Rate for Payer: BCBS Trust/PPO |
$7.03
|
| Rate for Payer: BCN Commercial |
$6.69
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cofinity Commercial |
$8.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.90
|
| Rate for Payer: Healthscope Commercial |
$8.63
|
| Rate for Payer: Healthscope Whirlpool |
$8.37
|
| Rate for Payer: Mclaren Commercial |
$7.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.34
|
| Rate for Payer: Nomi Health Commercial |
$7.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.59
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$6.37
|
|
|
Service Code
|
NDC 00406012323
|
| Hospital Charge Code |
34505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.14 |
| Max. Negotiated Rate |
$6.37 |
| Rate for Payer: Aetna Commercial |
$5.73
|
| Rate for Payer: ASR ASR |
$6.18
|
| Rate for Payer: ASR Commercial |
$6.18
|
| Rate for Payer: BCBS Trust/PPO |
$5.19
|
| Rate for Payer: BCN Commercial |
$4.94
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cofinity Commercial |
$5.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.10
|
| Rate for Payer: Healthscope Commercial |
$6.37
|
| Rate for Payer: Healthscope Whirlpool |
$6.18
|
| Rate for Payer: Mclaren Commercial |
$5.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.41
|
| Rate for Payer: Nomi Health Commercial |
$5.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.61
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
IP
|
$3.90
|
|
|
Service Code
|
NDC 50268040111
|
| Hospital Charge Code |
34505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: ASR ASR |
$3.78
|
| Rate for Payer: ASR Commercial |
$3.78
|
| Rate for Payer: BCBS Trust/PPO |
$3.18
|
| Rate for Payer: BCN Commercial |
$3.02
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cofinity Commercial |
$3.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.12
|
| Rate for Payer: Healthscope Commercial |
$3.90
|
| Rate for Payer: Healthscope Whirlpool |
$3.78
|
| Rate for Payer: Mclaren Commercial |
$3.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.31
|
| Rate for Payer: Nomi Health Commercial |
$3.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.43
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET
|
Facility
|
OP
|
$3.90
|
|
|
Service Code
|
NDC 50268040111
|
| Hospital Charge Code |
34505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Aetna Medicare |
$1.95
|
| Rate for Payer: ASR ASR |
$3.78
|
| Rate for Payer: ASR Commercial |
$3.78
|
| Rate for Payer: BCBS Complete |
$1.56
|
| Rate for Payer: BCBS Trust/PPO |
$3.19
|
| Rate for Payer: BCN Commercial |
$3.02
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cofinity Commercial |
$3.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.12
|
| Rate for Payer: Healthscope Commercial |
$3.90
|
| Rate for Payer: Healthscope Whirlpool |
$3.78
|
| Rate for Payer: Mclaren Commercial |
$3.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.31
|
| Rate for Payer: Nomi Health Commercial |
$3.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.42
|
| Rate for Payer: Priority Health Narrow Network |
$2.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.43
|
|
