|
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 |
$363.55
|
| 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 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 |
$341.93
|
| Rate for Payer: ASR Commercial |
$341.93
|
| 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 |
$341.93
|
| 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
|
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 |
$341.93
|
| Rate for Payer: ASR Commercial |
$341.93
|
| 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 |
$341.93
|
| 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
|
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
|
$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 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 |
$1.41
|
| 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
|
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
|
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 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 |
$361.67
|
| Rate for Payer: Aetna Medicare |
$200.93
|
| 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 |
$361.67
|
| 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
|
|
|
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
|
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 |
$361.67
|
| 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 |
$361.67
|
| 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
|
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 |
$162.93
|
| 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
|
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
|
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
|
|
|
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE
|
Facility
|
IP
|
$753.63
|
|
|
Service Code
|
HCPCS J7325
|
| Hospital Charge Code |
17381
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$489.86 |
| Max. Negotiated Rate |
$753.63 |
| Rate for Payer: Aetna Commercial |
$678.27
|
| Rate for Payer: ASR ASR |
$731.02
|
| Rate for Payer: ASR Commercial |
$731.02
|
| Rate for Payer: BCBS Trust/PPO |
$614.13
|
| Rate for Payer: BCN Commercial |
$584.29
|
| Rate for Payer: Cash Price |
$602.90
|
| Rate for Payer: Cofinity Commercial |
$708.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$602.90
|
| Rate for Payer: Healthscope Commercial |
$753.63
|
| Rate for Payer: Healthscope Whirlpool |
$731.02
|
| Rate for Payer: Mclaren Commercial |
$678.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$640.59
|
| Rate for Payer: Nomi Health Commercial |
$617.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$489.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$663.19
|
|
|
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE
|
Facility
|
OP
|
$753.63
|
|
|
Service Code
|
HCPCS J7325
|
| Hospital Charge Code |
17381
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.26 |
| Max. Negotiated Rate |
$753.63 |
| Rate for Payer: Aetna Commercial |
$678.27
|
| Rate for Payer: Aetna Medicare |
$7.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9.94
|
| Rate for Payer: ASR ASR |
$731.02
|
| Rate for Payer: ASR Commercial |
$731.02
|
| Rate for Payer: BCBS Complete |
$4.47
|
| Rate for Payer: BCBS MAPPO |
$7.95
|
| Rate for Payer: BCBS Trust/PPO |
$617.15
|
| Rate for Payer: BCN Commercial |
$584.29
|
| Rate for Payer: BCN Medicare Advantage |
$7.95
|
| Rate for Payer: Cash Price |
$602.90
|
| Rate for Payer: Cash Price |
$602.90
|
| Rate for Payer: Cofinity Commercial |
$708.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$602.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.95
|
| Rate for Payer: Healthscope Commercial |
$753.63
|
| Rate for Payer: Healthscope Whirlpool |
$731.02
|
| Rate for Payer: Humana Choice PPO Medicare |
$7.95
|
| Rate for Payer: Mclaren Commercial |
$678.27
|
| Rate for Payer: Mclaren Medicaid |
$4.26
|
| Rate for Payer: Mclaren Medicare |
$7.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.35
|
| Rate for Payer: Meridian Medicaid |
$4.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$640.59
|
| Rate for Payer: Nomi Health Commercial |
$617.98
|
| Rate for Payer: PACE Medicare |
$7.55
|
| Rate for Payer: PACE SWMI |
$7.95
|
| Rate for Payer: PHP Commercial |
$8.74
|
| Rate for Payer: PHP Medicaid |
$4.26
|
| Rate for Payer: PHP Medicare Advantage |
$7.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$489.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$660.33
|
| Rate for Payer: Priority Health Medicare |
$7.95
|
| Rate for Payer: Priority Health Narrow Network |
$528.29
|
| Rate for Payer: Railroad Medicare Medicare |
$7.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$663.19
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.95
|
| Rate for Payer: UHC Exchange |
$12.32
|
| Rate for Payer: UHC Medicare Advantage |
$7.95
|
| Rate for Payer: UHCCP DNSP |
$7.95
|
| Rate for Payer: UHCCP Medicaid |
$4.26
|
| Rate for Payer: VA VA |
$7.95
|
|
|
HYLAN G-F 20 48 MG/6 ML INTRA-ARTICULAR SYRINGE
|
Facility
|
IP
|
$2,037.98
|
|
|
Service Code
|
HCPCS J7325
|
| Hospital Charge Code |
118765
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,324.69 |
| Max. Negotiated Rate |
$2,037.98 |
| Rate for Payer: Aetna Commercial |
$1,834.18
|
| Rate for Payer: ASR ASR |
$1,976.84
|
| Rate for Payer: ASR Commercial |
$1,976.84
|
| Rate for Payer: BCBS Trust/PPO |
$1,660.75
|
| Rate for Payer: BCN Commercial |
$1,580.05
|
| Rate for Payer: Cash Price |
$1,630.39
|
| Rate for Payer: Cofinity Commercial |
$1,915.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,630.38
|
| Rate for Payer: Healthscope Commercial |
$2,037.98
|
| Rate for Payer: Healthscope Whirlpool |
$1,976.84
|
| Rate for Payer: Mclaren Commercial |
$1,834.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,732.28
|
| Rate for Payer: Nomi Health Commercial |
$1,671.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,324.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,793.42
|
|
|
HYLAN G-F 20 48 MG/6 ML INTRA-ARTICULAR SYRINGE
|
Facility
|
OP
|
$2,037.98
|
|
|
Service Code
|
HCPCS J7325
|
| Hospital Charge Code |
118765
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.26 |
| Max. Negotiated Rate |
$2,037.98 |
| Rate for Payer: Aetna Commercial |
$1,834.18
|
| Rate for Payer: Aetna Medicare |
$7.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9.94
|
| Rate for Payer: ASR ASR |
$1,976.84
|
| Rate for Payer: ASR Commercial |
$1,976.84
|
| Rate for Payer: BCBS Complete |
$4.47
|
| Rate for Payer: BCBS MAPPO |
$7.95
|
| Rate for Payer: BCBS Trust/PPO |
$1,668.90
|
| Rate for Payer: BCN Commercial |
$1,580.05
|
| Rate for Payer: BCN Medicare Advantage |
$7.95
|
| Rate for Payer: Cash Price |
$1,630.39
|
| Rate for Payer: Cash Price |
$1,630.39
|
| Rate for Payer: Cofinity Commercial |
$1,915.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,630.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.95
|
| Rate for Payer: Healthscope Commercial |
$2,037.98
|
| Rate for Payer: Healthscope Whirlpool |
$1,976.84
|
| Rate for Payer: Humana Choice PPO Medicare |
$7.95
|
| Rate for Payer: Mclaren Commercial |
$1,834.18
|
| Rate for Payer: Mclaren Medicaid |
$4.26
|
| Rate for Payer: Mclaren Medicare |
$7.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.35
|
| Rate for Payer: Meridian Medicaid |
$4.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,732.28
|
| Rate for Payer: Nomi Health Commercial |
$1,671.14
|
| Rate for Payer: PACE Medicare |
$7.55
|
| Rate for Payer: PACE SWMI |
$7.95
|
| Rate for Payer: PHP Commercial |
$8.74
|
| Rate for Payer: PHP Medicaid |
$4.26
|
| Rate for Payer: PHP Medicare Advantage |
$7.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,324.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,785.68
|
| Rate for Payer: Priority Health Medicare |
$7.95
|
| Rate for Payer: Priority Health Narrow Network |
$1,428.62
|
| Rate for Payer: Railroad Medicare Medicare |
$7.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,793.42
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.95
|
| Rate for Payer: UHC Exchange |
$12.32
|
| Rate for Payer: UHC Medicare Advantage |
$7.95
|
| Rate for Payer: UHCCP DNSP |
$7.95
|
| Rate for Payer: UHCCP Medicaid |
$4.26
|
| Rate for Payer: VA VA |
$7.95
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
IP
|
$302.40
|
|
|
Service Code
|
NDC 43199001101
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.56 |
| Max. Negotiated Rate |
$302.40 |
| Rate for Payer: Aetna Commercial |
$272.16
|
| Rate for Payer: ASR ASR |
$293.33
|
| Rate for Payer: ASR Commercial |
$293.33
|
| Rate for Payer: BCBS Trust/PPO |
$246.43
|
| Rate for Payer: BCN Commercial |
$234.45
|
| Rate for Payer: Cash Price |
$241.92
|
| Rate for Payer: Cofinity Commercial |
$284.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$241.92
|
| Rate for Payer: Healthscope Commercial |
$302.40
|
| Rate for Payer: Healthscope Whirlpool |
$293.33
|
| Rate for Payer: Mclaren Commercial |
$272.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$257.04
|
| Rate for Payer: Nomi Health Commercial |
$247.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$196.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$266.11
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET
|
Facility
|
OP
|
$302.40
|
|
|
Service Code
|
NDC 43199001101
|
| Hospital Charge Code |
17023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.96 |
| Max. Negotiated Rate |
$302.40 |
| Rate for Payer: Aetna Commercial |
$272.16
|
| Rate for Payer: Aetna Medicare |
$151.20
|
| Rate for Payer: ASR ASR |
$293.33
|
| Rate for Payer: ASR Commercial |
$293.33
|
| Rate for Payer: BCBS Complete |
$120.96
|
| Rate for Payer: BCBS Trust/PPO |
$247.64
|
| Rate for Payer: BCN Commercial |
$234.45
|
| Rate for Payer: Cash Price |
$241.92
|
| Rate for Payer: Cofinity Commercial |
$284.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$241.92
|
| Rate for Payer: Healthscope Commercial |
$302.40
|
| Rate for Payer: Healthscope Whirlpool |
$293.33
|
| Rate for Payer: Mclaren Commercial |
$272.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$257.04
|
| Rate for Payer: Nomi Health Commercial |
$247.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$196.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$264.96
|
| Rate for Payer: Priority Health Narrow Network |
$211.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$266.11
|
|
|
HYOSCYAMINE SULFATE 0.125 MG TABLET
|
Facility
|
IP
|
$204.45
|
|
|
Service Code
|
NDC 47781001301
|
| Hospital Charge Code |
3783
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.89 |
| Max. Negotiated Rate |
$204.45 |
| Rate for Payer: Aetna Commercial |
$184.00
|
| Rate for Payer: ASR ASR |
$198.32
|
| Rate for Payer: ASR Commercial |
$198.32
|
| Rate for Payer: BCBS Trust/PPO |
$166.61
|
| Rate for Payer: BCN Commercial |
$158.51
|
| Rate for Payer: Cash Price |
$163.56
|
| Rate for Payer: Cofinity Commercial |
$192.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.56
|
| Rate for Payer: Healthscope Commercial |
$204.45
|
| Rate for Payer: Healthscope Whirlpool |
$198.32
|
| Rate for Payer: Mclaren Commercial |
$184.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.78
|
| Rate for Payer: Nomi Health Commercial |
$167.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$179.92
|
|
|
HYOSCYAMINE SULFATE 0.125 MG TABLET
|
Facility
|
OP
|
$204.45
|
|
|
Service Code
|
NDC 47781001301
|
| Hospital Charge Code |
3783
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.78 |
| Max. Negotiated Rate |
$204.45 |
| Rate for Payer: Aetna Commercial |
$184.00
|
| Rate for Payer: Aetna Medicare |
$102.22
|
| Rate for Payer: ASR ASR |
$198.32
|
| Rate for Payer: ASR Commercial |
$198.32
|
| Rate for Payer: BCBS Complete |
$81.78
|
| Rate for Payer: BCBS Trust/PPO |
$167.42
|
| Rate for Payer: BCN Commercial |
$158.51
|
| Rate for Payer: Cash Price |
$163.56
|
| Rate for Payer: Cofinity Commercial |
$192.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.56
|
| Rate for Payer: Healthscope Commercial |
$204.45
|
| Rate for Payer: Healthscope Whirlpool |
$198.32
|
| Rate for Payer: Mclaren Commercial |
$184.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.78
|
| Rate for Payer: Nomi Health Commercial |
$167.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.89
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$179.14
|
| Rate for Payer: Priority Health Narrow Network |
$143.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$179.92
|
|
|
HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)
|
Facility
|
OP
|
$7,462.35
|
|
|
Service Code
|
CPT 58563
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,580.53 |
| Max. Negotiated Rate |
$7,462.35 |
| Rate for Payer: Aetna Medicare |
$4,814.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,018.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,018.02
|
| Rate for Payer: BCBS Complete |
$2,709.56
|
| Rate for Payer: BCBS MAPPO |
$4,814.42
|
| Rate for Payer: BCN Medicare Advantage |
$4,814.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,814.42
|
| Rate for Payer: Humana Choice PPO Medicare |
$4,814.42
|
| Rate for Payer: Mclaren Medicaid |
$2,580.53
|
| Rate for Payer: Mclaren Medicare |
$4,814.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,055.14
|
| Rate for Payer: Meridian Medicaid |
$2,709.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,536.58
|
| Rate for Payer: PACE Medicare |
$4,573.70
|
| Rate for Payer: PACE SWMI |
$4,814.42
|
| Rate for Payer: PHP Commercial |
$5,295.86
|
| Rate for Payer: PHP Medicaid |
$2,580.53
|
| Rate for Payer: PHP Medicare Advantage |
$4,814.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,580.53
|
| Rate for Payer: Priority Health Medicare |
$4,814.42
|
| Rate for Payer: Railroad Medicare Medicare |
$4,814.42
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,814.42
|
| Rate for Payer: UHC Exchange |
$7,462.35
|
| Rate for Payer: UHC Medicare Advantage |
$4,814.42
|
| Rate for Payer: UHCCP DNSP |
$4,814.42
|
| Rate for Payer: UHCCP Medicaid |
$2,580.53
|
| Rate for Payer: VA VA |
$4,814.42
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$2.64
|
|
|
Service Code
|
NDC 68094049459
|
| Hospital Charge Code |
10246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Aetna Commercial |
$2.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: ASR ASR |
$2.56
|
| Rate for Payer: ASR Commercial |
$2.56
|
| Rate for Payer: BCBS Complete |
$1.06
|
| Rate for Payer: BCBS Trust/PPO |
$2.16
|
| Rate for Payer: BCN Commercial |
$2.05
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cofinity Commercial |
$2.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.11
|
| Rate for Payer: Healthscope Commercial |
$2.64
|
| Rate for Payer: Healthscope Whirlpool |
$2.56
|
| Rate for Payer: Mclaren Commercial |
$2.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.24
|
| Rate for Payer: Nomi Health Commercial |
$2.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.31
|
| Rate for Payer: Priority Health Narrow Network |
$1.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.32
|
|
