|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
OP
|
$275.50
|
|
|
Service Code
|
NDC 43598072101
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.20 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna Commercial |
$247.95
|
| Rate for Payer: Aetna Medicare |
$137.75
|
| Rate for Payer: ASR ASR |
$267.24
|
| Rate for Payer: ASR Commercial |
$267.24
|
| Rate for Payer: BCBS Complete |
$110.20
|
| Rate for Payer: BCBS Trust/PPO |
$225.61
|
| Rate for Payer: BCN Commercial |
$213.60
|
| Rate for Payer: Cash Price |
$220.40
|
| Rate for Payer: Cofinity Commercial |
$258.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.40
|
| Rate for Payer: Healthscope Commercial |
$275.50
|
| Rate for Payer: Healthscope Whirlpool |
$267.24
|
| Rate for Payer: Mclaren Commercial |
$247.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.18
|
| Rate for Payer: Nomi Health Commercial |
$225.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$241.39
|
| Rate for Payer: Priority Health Narrow Network |
$193.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$242.44
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
OP
|
$195.12
|
|
|
Service Code
|
NDC 00904704606
|
| Hospital Charge Code |
10235
|
|
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
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
IP
|
$291.65
|
|
|
Service Code
|
NDC 69238154401
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$189.57 |
| Max. Negotiated Rate |
$291.65 |
| Rate for Payer: Aetna Commercial |
$262.48
|
| Rate for Payer: ASR ASR |
$282.90
|
| Rate for Payer: ASR Commercial |
$282.90
|
| Rate for Payer: BCBS Trust/PPO |
$237.67
|
| Rate for Payer: BCN Commercial |
$226.12
|
| Rate for Payer: Cash Price |
$233.32
|
| Rate for Payer: Cofinity Commercial |
$274.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.32
|
| Rate for Payer: Healthscope Commercial |
$291.65
|
| Rate for Payer: Healthscope Whirlpool |
$282.90
|
| Rate for Payer: Mclaren Commercial |
$262.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.90
|
| Rate for Payer: Nomi Health Commercial |
$239.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$256.65
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
IP
|
$195.12
|
|
|
Service Code
|
NDC 00904704606
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.83 |
| Max. Negotiated Rate |
$195.12 |
| Rate for Payer: Aetna Commercial |
$175.61
|
| Rate for Payer: ASR ASR |
$189.27
|
| Rate for Payer: ASR Commercial |
$189.27
|
| Rate for Payer: BCBS Trust/PPO |
$159.00
|
| 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: UHC All Payor (Choice/PPO) + Core |
$171.71
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET
|
Facility
|
IP
|
$275.50
|
|
|
Service Code
|
NDC 43598072101
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.08 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna Commercial |
$247.95
|
| Rate for Payer: ASR ASR |
$267.24
|
| Rate for Payer: ASR Commercial |
$267.24
|
| Rate for Payer: BCBS Trust/PPO |
$224.50
|
| Rate for Payer: BCN Commercial |
$213.60
|
| Rate for Payer: Cash Price |
$220.40
|
| Rate for Payer: Cofinity Commercial |
$258.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.40
|
| Rate for Payer: Healthscope Commercial |
$275.50
|
| Rate for Payer: Healthscope Whirlpool |
$267.24
|
| Rate for Payer: Mclaren Commercial |
$247.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.18
|
| Rate for Payer: Nomi Health Commercial |
$225.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$242.44
|
|
|
HYDROXYPROGESTERONE (PF)(PREGNANCY PRESERVING) 250 MG/ML (1 ML) IM OIL
|
Facility
|
OP
|
$2,128.29
|
|
|
Service Code
|
HCPCS J1726
|
| Hospital Charge Code |
178180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.41 |
| Max. Negotiated Rate |
$2,128.29 |
| Rate for Payer: Aetna Commercial |
$1,915.46
|
| Rate for Payer: Aetna Commercial |
$1,838.76
|
| Rate for Payer: Aetna Medicare |
$13.82
|
| Rate for Payer: Aetna Medicare |
$13.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17.28
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17.28
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17.28
|
| Rate for Payer: ASR ASR |
$2,064.44
|
| Rate for Payer: ASR ASR |
$1,981.78
|
| Rate for Payer: ASR Commercial |
$1,981.78
|
| Rate for Payer: ASR Commercial |
$2,064.44
|
| Rate for Payer: BCBS Complete |
$7.78
|
| Rate for Payer: BCBS Complete |
$7.78
|
| Rate for Payer: BCBS MAPPO |
$13.82
|
| Rate for Payer: BCBS MAPPO |
$13.82
|
| Rate for Payer: BCBS Trust/PPO |
$1,742.86
|
| Rate for Payer: BCBS Trust/PPO |
$1,673.07
|
| Rate for Payer: BCN Commercial |
$1,583.99
|
| Rate for Payer: BCN Commercial |
$1,650.06
|
| Rate for Payer: BCN Medicare Advantage |
$13.82
|
| Rate for Payer: BCN Medicare Advantage |
$13.82
|
| Rate for Payer: Cash Price |
$1,702.63
|
| Rate for Payer: Cash Price |
$1,634.46
|
| Rate for Payer: Cash Price |
$1,702.63
|
| Rate for Payer: Cash Price |
$1,634.46
|
| Rate for Payer: Cofinity Commercial |
$1,920.49
|
| Rate for Payer: Cofinity Commercial |
$2,000.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,702.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,634.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.82
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.82
|
| Rate for Payer: Healthscope Commercial |
$2,043.07
|
| Rate for Payer: Healthscope Commercial |
$2,128.29
|
| Rate for Payer: Healthscope Whirlpool |
$1,981.78
|
| Rate for Payer: Healthscope Whirlpool |
$2,064.44
|
| Rate for Payer: Humana Choice PPO Medicare |
$13.82
|
| Rate for Payer: Humana Choice PPO Medicare |
$13.82
|
| Rate for Payer: Mclaren Commercial |
$1,838.76
|
| Rate for Payer: Mclaren Commercial |
$1,915.46
|
| Rate for Payer: Mclaren Medicaid |
$7.41
|
| Rate for Payer: Mclaren Medicaid |
$7.41
|
| Rate for Payer: Mclaren Medicare |
$13.82
|
| Rate for Payer: Mclaren Medicare |
$13.82
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14.51
|
| Rate for Payer: Meridian Medicaid |
$7.78
|
| Rate for Payer: Meridian Medicaid |
$7.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,809.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,736.61
|
| Rate for Payer: Nomi Health Commercial |
$1,745.20
|
| Rate for Payer: Nomi Health Commercial |
$1,675.32
|
| Rate for Payer: PACE Medicare |
$13.13
|
| Rate for Payer: PACE Medicare |
$13.13
|
| Rate for Payer: PACE SWMI |
$13.82
|
| Rate for Payer: PACE SWMI |
$13.82
|
| Rate for Payer: PHP Commercial |
$15.20
|
| Rate for Payer: PHP Commercial |
$15.20
|
| Rate for Payer: PHP Medicaid |
$7.41
|
| Rate for Payer: PHP Medicaid |
$7.41
|
| Rate for Payer: PHP Medicare Advantage |
$13.82
|
| Rate for Payer: PHP Medicare Advantage |
$13.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$7.41
|
| Rate for Payer: Priority Health Choice Medicaid |
$7.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,328.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,383.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.62
|
| Rate for Payer: Priority Health Medicare |
$13.82
|
| Rate for Payer: Priority Health Medicare |
$13.82
|
| Rate for Payer: Priority Health Narrow Network |
$16.50
|
| Rate for Payer: Priority Health Narrow Network |
$16.50
|
| Rate for Payer: Railroad Medicare Medicare |
$13.82
|
| Rate for Payer: Railroad Medicare Medicare |
$13.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,797.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,872.90
|
| Rate for Payer: UHC Dual Complete DSNP |
$13.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$13.82
|
| Rate for Payer: UHC Exchange |
$21.42
|
| Rate for Payer: UHC Exchange |
$21.42
|
| Rate for Payer: UHC Medicare Advantage |
$13.82
|
| Rate for Payer: UHC Medicare Advantage |
$13.82
|
| Rate for Payer: UHCCP DNSP |
$13.82
|
| Rate for Payer: UHCCP DNSP |
$13.82
|
| Rate for Payer: UHCCP Medicaid |
$7.41
|
| Rate for Payer: UHCCP Medicaid |
$7.41
|
| Rate for Payer: VA VA |
$13.82
|
| Rate for Payer: VA VA |
$13.82
|
|
|
HYDROXYPROGESTERONE (PF)(PREGNANCY PRESERVING) 250 MG/ML (1 ML) IM OIL
|
Facility
|
IP
|
$2,043.07
|
|
|
Service Code
|
HCPCS J1726
|
| Hospital Charge Code |
178180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,328.00 |
| Max. Negotiated Rate |
$2,043.07 |
| Rate for Payer: Aetna Commercial |
$1,838.76
|
| Rate for Payer: Aetna Commercial |
$1,915.46
|
| Rate for Payer: ASR ASR |
$2,064.44
|
| Rate for Payer: ASR ASR |
$1,981.78
|
| Rate for Payer: ASR Commercial |
$2,064.44
|
| Rate for Payer: ASR Commercial |
$1,981.78
|
| Rate for Payer: BCBS Trust/PPO |
$1,734.34
|
| Rate for Payer: BCBS Trust/PPO |
$1,664.90
|
| Rate for Payer: BCN Commercial |
$1,650.06
|
| Rate for Payer: BCN Commercial |
$1,583.99
|
| Rate for Payer: Cash Price |
$1,634.46
|
| Rate for Payer: Cash Price |
$1,702.63
|
| Rate for Payer: Cofinity Commercial |
$2,000.59
|
| Rate for Payer: Cofinity Commercial |
$1,920.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,634.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,702.63
|
| Rate for Payer: Healthscope Commercial |
$2,043.07
|
| Rate for Payer: Healthscope Commercial |
$2,128.29
|
| Rate for Payer: Healthscope Whirlpool |
$2,064.44
|
| Rate for Payer: Healthscope Whirlpool |
$1,981.78
|
| Rate for Payer: Mclaren Commercial |
$1,838.76
|
| Rate for Payer: Mclaren Commercial |
$1,915.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,809.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,736.61
|
| Rate for Payer: Nomi Health Commercial |
$1,745.20
|
| Rate for Payer: Nomi Health Commercial |
$1,675.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,328.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,383.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,797.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,872.90
|
|
|
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 |
$427.70 |
| Rate for Payer: Aetna Commercial |
$384.93
|
| Rate for Payer: ASR ASR |
$414.87
|
| Rate for Payer: ASR Commercial |
$414.87
|
| Rate for Payer: BCBS Trust/PPO |
$348.53
|
| Rate for Payer: BCN Commercial |
$331.60
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$402.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Healthscope Commercial |
$427.70
|
| Rate for Payer: Healthscope Whirlpool |
$414.87
|
| Rate for Payer: Mclaren Commercial |
$384.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$363.54
|
| Rate for Payer: Nomi Health Commercial |
$350.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$376.38
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
OP
|
$427.70
|
|
|
Service Code
|
NDC 68084025301
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.08 |
| Max. Negotiated Rate |
$427.70 |
| Rate for Payer: Aetna Commercial |
$384.93
|
| Rate for Payer: Aetna Medicare |
$213.85
|
| Rate for Payer: ASR ASR |
$414.87
|
| Rate for Payer: ASR Commercial |
$414.87
|
| Rate for Payer: BCBS Complete |
$171.08
|
| Rate for Payer: BCBS Trust/PPO |
$350.24
|
| Rate for Payer: BCN Commercial |
$331.60
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$402.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Healthscope Commercial |
$427.70
|
| Rate for Payer: Healthscope Whirlpool |
$414.87
|
| Rate for Payer: Mclaren Commercial |
$384.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$363.54
|
| Rate for Payer: Nomi Health Commercial |
$350.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$374.75
|
| Rate for Payer: Priority Health Narrow Network |
$299.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$376.38
|
|
|
HYDROXYZINE HCL 10 MG TABLET
|
Facility
|
OP
|
$427.70
|
|
|
Service Code
|
NDC 68084025311
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.08 |
| Max. Negotiated Rate |
$427.70 |
| Rate for Payer: Aetna Commercial |
$384.93
|
| Rate for Payer: Aetna Medicare |
$213.85
|
| Rate for Payer: ASR ASR |
$414.87
|
| Rate for Payer: ASR Commercial |
$414.87
|
| Rate for Payer: BCBS Complete |
$171.08
|
| Rate for Payer: BCBS Trust/PPO |
$350.24
|
| Rate for Payer: BCN Commercial |
$331.60
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$402.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Healthscope Commercial |
$427.70
|
| Rate for Payer: Healthscope Whirlpool |
$414.87
|
| Rate for Payer: Mclaren Commercial |
$384.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$363.54
|
| Rate for Payer: Nomi Health Commercial |
$350.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$374.75
|
| Rate for Payer: Priority Health Narrow Network |
$299.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$376.38
|
|
|
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 |
$427.70 |
| Rate for Payer: Aetna Commercial |
$384.93
|
| Rate for Payer: ASR ASR |
$414.87
|
| Rate for Payer: ASR Commercial |
$414.87
|
| Rate for Payer: BCBS Trust/PPO |
$348.53
|
| Rate for Payer: BCN Commercial |
$331.60
|
| Rate for Payer: Cash Price |
$342.16
|
| Rate for Payer: Cofinity Commercial |
$402.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.16
|
| Rate for Payer: Healthscope Commercial |
$427.70
|
| Rate for Payer: Healthscope Whirlpool |
$414.87
|
| Rate for Payer: Mclaren Commercial |
$384.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$363.54
|
| Rate for Payer: Nomi Health Commercial |
$350.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$376.38
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
IP
|
$2.81
|
|
|
Service Code
|
NDC 68084025411
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Aetna Commercial |
$2.53
|
| Rate for Payer: ASR ASR |
$2.73
|
| Rate for Payer: ASR Commercial |
$2.73
|
| Rate for Payer: BCBS Trust/PPO |
$2.29
|
| Rate for Payer: BCN Commercial |
$2.18
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cofinity Commercial |
$2.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.25
|
| Rate for Payer: Healthscope Commercial |
$2.81
|
| Rate for Payer: Healthscope Whirlpool |
$2.73
|
| Rate for Payer: Mclaren Commercial |
$2.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.39
|
| Rate for Payer: Nomi Health Commercial |
$2.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.47
|
|
|
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 |
$352.50 |
| Rate for Payer: Aetna Commercial |
$317.25
|
| Rate for Payer: ASR ASR |
$341.92
|
| Rate for Payer: ASR Commercial |
$341.92
|
| Rate for Payer: BCBS Trust/PPO |
$287.25
|
| Rate for Payer: BCN Commercial |
$273.29
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cofinity Commercial |
$331.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.00
|
| Rate for Payer: Healthscope Commercial |
$352.50
|
| Rate for Payer: Healthscope Whirlpool |
$341.92
|
| Rate for Payer: Mclaren Commercial |
$317.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$299.62
|
| Rate for Payer: Nomi Health Commercial |
$289.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$310.20
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
OP
|
$352.50
|
|
|
Service Code
|
NDC 00904661761
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.00 |
| Max. Negotiated Rate |
$352.50 |
| Rate for Payer: Aetna Commercial |
$317.25
|
| Rate for Payer: Aetna Medicare |
$176.25
|
| Rate for Payer: ASR ASR |
$341.92
|
| Rate for Payer: ASR Commercial |
$341.92
|
| Rate for Payer: BCBS Complete |
$141.00
|
| Rate for Payer: BCBS Trust/PPO |
$288.66
|
| Rate for Payer: BCN Commercial |
$273.29
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cofinity Commercial |
$331.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.00
|
| Rate for Payer: Healthscope Commercial |
$352.50
|
| Rate for Payer: Healthscope Whirlpool |
$341.92
|
| Rate for Payer: Mclaren Commercial |
$317.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$299.62
|
| Rate for Payer: Nomi Health Commercial |
$289.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$308.86
|
| Rate for Payer: Priority Health Narrow Network |
$247.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$310.20
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
OP
|
$441.80
|
|
|
Service Code
|
NDC 63739048610
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.72 |
| Max. Negotiated Rate |
$441.80 |
| Rate for Payer: Aetna Commercial |
$397.62
|
| Rate for Payer: Aetna Medicare |
$220.90
|
| Rate for Payer: ASR ASR |
$428.55
|
| Rate for Payer: ASR Commercial |
$428.55
|
| Rate for Payer: BCBS Complete |
$176.72
|
| Rate for Payer: BCBS Trust/PPO |
$361.79
|
| Rate for Payer: BCN Commercial |
$342.53
|
| Rate for Payer: Cash Price |
$353.44
|
| Rate for Payer: Cofinity Commercial |
$415.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.44
|
| Rate for Payer: Healthscope Commercial |
$441.80
|
| Rate for Payer: Healthscope Whirlpool |
$428.55
|
| Rate for Payer: Mclaren Commercial |
$397.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$375.53
|
| Rate for Payer: Nomi Health Commercial |
$362.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$387.11
|
| Rate for Payer: Priority Health Narrow Network |
$309.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$388.78
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
IP
|
$441.80
|
|
|
Service Code
|
NDC 63739048610
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$287.17 |
| Max. Negotiated Rate |
$441.80 |
| Rate for Payer: Aetna Commercial |
$397.62
|
| Rate for Payer: ASR ASR |
$428.55
|
| Rate for Payer: ASR Commercial |
$428.55
|
| Rate for Payer: BCBS Trust/PPO |
$360.02
|
| Rate for Payer: BCN Commercial |
$342.53
|
| Rate for Payer: Cash Price |
$353.44
|
| Rate for Payer: Cofinity Commercial |
$415.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.44
|
| Rate for Payer: Healthscope Commercial |
$441.80
|
| Rate for Payer: Healthscope Whirlpool |
$428.55
|
| Rate for Payer: Mclaren Commercial |
$397.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$375.53
|
| Rate for Payer: Nomi Health Commercial |
$362.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$388.78
|
|
|
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 |
$281.20 |
| Rate for Payer: Aetna Commercial |
$253.08
|
| Rate for Payer: ASR ASR |
$272.76
|
| Rate for Payer: ASR Commercial |
$272.76
|
| Rate for Payer: BCBS Trust/PPO |
$229.15
|
| Rate for Payer: BCN Commercial |
$218.01
|
| Rate for Payer: Cash Price |
$224.96
|
| Rate for Payer: Cofinity Commercial |
$264.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.96
|
| Rate for Payer: Healthscope Commercial |
$281.20
|
| Rate for Payer: Healthscope Whirlpool |
$272.76
|
| Rate for Payer: Mclaren Commercial |
$253.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.02
|
| Rate for Payer: Nomi Health Commercial |
$230.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$247.46
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
OP
|
$2.81
|
|
|
Service Code
|
NDC 68084025411
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Aetna Commercial |
$2.53
|
| Rate for Payer: Aetna Medicare |
$1.40
|
| Rate for Payer: ASR ASR |
$2.73
|
| Rate for Payer: ASR Commercial |
$2.73
|
| Rate for Payer: BCBS Complete |
$1.12
|
| Rate for Payer: BCBS Trust/PPO |
$2.30
|
| Rate for Payer: BCN Commercial |
$2.18
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cofinity Commercial |
$2.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.25
|
| Rate for Payer: Healthscope Commercial |
$2.81
|
| Rate for Payer: Healthscope Whirlpool |
$2.73
|
| Rate for Payer: Mclaren Commercial |
$2.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.39
|
| Rate for Payer: Nomi Health Commercial |
$2.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.46
|
| Rate for Payer: Priority Health Narrow Network |
$1.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.47
|
|
|
HYDROXYZINE HCL 25 MG TABLET
|
Facility
|
OP
|
$281.20
|
|
|
Service Code
|
NDC 68084025401
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.48 |
| Max. Negotiated Rate |
$281.20 |
| Rate for Payer: Aetna Commercial |
$253.08
|
| Rate for Payer: Aetna Medicare |
$140.60
|
| Rate for Payer: ASR ASR |
$272.76
|
| Rate for Payer: ASR Commercial |
$272.76
|
| Rate for Payer: BCBS Complete |
$112.48
|
| Rate for Payer: BCBS Trust/PPO |
$230.27
|
| Rate for Payer: BCN Commercial |
$218.01
|
| Rate for Payer: Cash Price |
$224.96
|
| Rate for Payer: Cofinity Commercial |
$264.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.96
|
| Rate for Payer: Healthscope Commercial |
$281.20
|
| Rate for Payer: Healthscope Whirlpool |
$272.76
|
| Rate for Payer: Mclaren Commercial |
$253.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.02
|
| Rate for Payer: Nomi Health Commercial |
$230.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$246.39
|
| Rate for Payer: Priority Health Narrow Network |
$197.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$247.46
|
|
|
HYDROXYZINE PAMOATE 25 MG CAPSULE
|
Facility
|
OP
|
$325.85
|
|
|
Service Code
|
NDC 00904706561
|
| Hospital Charge Code |
3777
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.34 |
| Max. Negotiated Rate |
$325.85 |
| Rate for Payer: Aetna Commercial |
$293.26
|
| Rate for Payer: Aetna Medicare |
$162.92
|
| Rate for Payer: ASR ASR |
$316.07
|
| Rate for Payer: ASR Commercial |
$316.07
|
| Rate for Payer: BCBS Complete |
$130.34
|
| Rate for Payer: BCBS Trust/PPO |
$266.84
|
| Rate for Payer: BCN Commercial |
$252.63
|
| Rate for Payer: Cash Price |
$260.68
|
| Rate for Payer: Cofinity Commercial |
$306.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.68
|
| Rate for Payer: Healthscope Commercial |
$325.85
|
| Rate for Payer: Healthscope Whirlpool |
$316.07
|
| Rate for Payer: Mclaren Commercial |
$293.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.97
|
| Rate for Payer: Nomi Health Commercial |
$267.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$285.51
|
| Rate for Payer: Priority Health Narrow Network |
$228.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$286.75
|
|
|
HYDROXYZINE PAMOATE 25 MG CAPSULE
|
Facility
|
IP
|
$162.15
|
|
|
Service Code
|
NDC 00185067401
|
| Hospital Charge Code |
3777
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.40 |
| Max. Negotiated Rate |
$162.15 |
| Rate for Payer: Aetna Commercial |
$145.94
|
| Rate for Payer: ASR ASR |
$157.29
|
| Rate for Payer: ASR Commercial |
$157.29
|
| Rate for Payer: BCBS Trust/PPO |
$132.14
|
| Rate for Payer: BCN Commercial |
$125.71
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Commercial |
$152.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$162.15
|
| Rate for Payer: Healthscope Whirlpool |
$157.29
|
| Rate for Payer: Mclaren Commercial |
$145.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.83
|
| Rate for Payer: Nomi Health Commercial |
$132.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$142.69
|
|
|
HYDROXYZINE PAMOATE 25 MG CAPSULE
|
Facility
|
IP
|
$401.85
|
|
|
Service Code
|
NDC 00069541066
|
| Hospital Charge Code |
3777
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$261.20 |
| Max. Negotiated Rate |
$401.85 |
| Rate for Payer: Aetna Commercial |
$361.66
|
| Rate for Payer: ASR ASR |
$389.79
|
| Rate for Payer: ASR Commercial |
$389.79
|
| Rate for Payer: BCBS Trust/PPO |
$327.47
|
| Rate for Payer: BCN Commercial |
$311.55
|
| Rate for Payer: Cash Price |
$321.48
|
| Rate for Payer: Cofinity Commercial |
$377.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.48
|
| Rate for Payer: Healthscope Commercial |
$401.85
|
| Rate for Payer: Healthscope Whirlpool |
$389.79
|
| Rate for Payer: Mclaren Commercial |
$361.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$341.57
|
| Rate for Payer: Nomi Health Commercial |
$329.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$261.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$353.63
|
|
|
HYDROXYZINE PAMOATE 25 MG CAPSULE
|
Facility
|
IP
|
$325.85
|
|
|
Service Code
|
NDC 00904706561
|
| Hospital Charge Code |
3777
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$211.80 |
| Max. Negotiated Rate |
$325.85 |
| Rate for Payer: Aetna Commercial |
$293.26
|
| Rate for Payer: ASR ASR |
$316.07
|
| Rate for Payer: ASR Commercial |
$316.07
|
| Rate for Payer: BCBS Trust/PPO |
$265.54
|
| Rate for Payer: BCN Commercial |
$252.63
|
| Rate for Payer: Cash Price |
$260.68
|
| Rate for Payer: Cofinity Commercial |
$306.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.68
|
| Rate for Payer: Healthscope Commercial |
$325.85
|
| Rate for Payer: Healthscope Whirlpool |
$316.07
|
| Rate for Payer: Mclaren Commercial |
$293.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.97
|
| Rate for Payer: Nomi Health Commercial |
$267.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$286.75
|
|
|
HYDROXYZINE PAMOATE 25 MG CAPSULE
|
Facility
|
OP
|
$162.15
|
|
|
Service Code
|
NDC 00185067401
|
| Hospital Charge Code |
3777
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.86 |
| Max. Negotiated Rate |
$162.15 |
| Rate for Payer: Aetna Commercial |
$145.94
|
| Rate for Payer: Aetna Medicare |
$81.08
|
| Rate for Payer: ASR ASR |
$157.29
|
| Rate for Payer: ASR Commercial |
$157.29
|
| Rate for Payer: BCBS Complete |
$64.86
|
| Rate for Payer: BCBS Trust/PPO |
$132.78
|
| Rate for Payer: BCN Commercial |
$125.71
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Commercial |
$152.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$162.15
|
| Rate for Payer: Healthscope Whirlpool |
$157.29
|
| Rate for Payer: Mclaren Commercial |
$145.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.83
|
| Rate for Payer: Nomi Health Commercial |
$132.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$142.08
|
| Rate for Payer: Priority Health Narrow Network |
$113.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$142.69
|
|
|
HYDROXYZINE PAMOATE 25 MG CAPSULE
|
Facility
|
OP
|
$401.85
|
|
|
Service Code
|
NDC 00069541066
|
| Hospital Charge Code |
3777
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.74 |
| Max. Negotiated Rate |
$401.85 |
| Rate for Payer: Aetna Commercial |
$361.66
|
| Rate for Payer: Aetna Medicare |
$200.92
|
| Rate for Payer: ASR ASR |
$389.79
|
| Rate for Payer: ASR Commercial |
$389.79
|
| Rate for Payer: BCBS Complete |
$160.74
|
| Rate for Payer: BCBS Trust/PPO |
$329.07
|
| Rate for Payer: BCN Commercial |
$311.55
|
| Rate for Payer: Cash Price |
$321.48
|
| Rate for Payer: Cofinity Commercial |
$377.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.48
|
| Rate for Payer: Healthscope Commercial |
$401.85
|
| Rate for Payer: Healthscope Whirlpool |
$389.79
|
| Rate for Payer: Mclaren Commercial |
$361.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$341.57
|
| Rate for Payer: Nomi Health Commercial |
$329.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$261.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$352.10
|
| Rate for Payer: Priority Health Narrow Network |
$281.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$353.63
|
|
