|
HYDROCHLOROTHIAZIDE 12.5 MG ORAL TAB
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 69315015501
|
| Hospital Charge Code |
76988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna Commercial |
$1.03
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna All Commercial |
$1.03
|
| Rate for Payer: CORVEL All Commercial |
$1.11
|
| Rate for Payer: Coventry All Commercial |
$1.05
|
| Rate for Payer: Encore All Commercial |
$1.10
|
| Rate for Payer: Frontpath All Commercial |
$1.10
|
| Rate for Payer: Humana ChoiceCare |
$1.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.08
|
| Rate for Payer: PHCS All Commercial |
$0.90
|
| Rate for Payer: PHP All Commercial |
$0.91
|
| Rate for Payer: Sagamore Health Network All Products |
$0.92
|
| Rate for Payer: Signature Care EPO |
$0.99
|
| Rate for Payer: Signature Care PPO |
$1.05
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
|
|
HYDROCHLOROTHIAZIDE 25 MG ORAL TAB
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 29300012801
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.54
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
HYDROCHLOROTHIAZIDE 25 MG ORAL TAB
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 29300012801
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00406012562
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00406012562
|
| Hospital Charge Code |
28384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00406012362
|
| Hospital Charge Code |
34505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00406012362
|
| Hospital Charge Code |
34505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68084089501
|
| Hospital Charge Code |
34505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68084089501
|
| Hospital Charge Code |
34505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00406012323
|
| Hospital Charge Code |
34505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
|
|
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00406012323
|
| Hospital Charge Code |
34505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Centivo All Commercial |
$2.18
|
| Rate for Payer: Cigna All Commercial |
$3.45
|
| Rate for Payer: CORVEL All Commercial |
$3.72
|
| Rate for Payer: Coventry All Commercial |
$3.52
|
| Rate for Payer: Encore All Commercial |
$3.68
|
| Rate for Payer: Frontpath All Commercial |
$3.68
|
| Rate for Payer: Humana ChoiceCare |
$3.45
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Lucent All Commercial |
$2.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.60
|
| Rate for Payer: PHCS All Commercial |
$3.00
|
| Rate for Payer: PHP All Commercial |
$3.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.56
|
| Rate for Payer: Sagamore Health Network All Products |
$3.09
|
| Rate for Payer: Signature Care EPO |
$3.32
|
| Rate for Payer: Signature Care PPO |
$3.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.40
|
| Rate for Payer: United Healthcare Commercial |
$3.15
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
|
|
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML ORAL SOLN
|
Facility
|
IP
|
$33.81
|
|
|
Service Code
|
NDC 00121231615
|
| Hospital Charge Code |
37848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.36 |
| Max. Negotiated Rate |
$31.44 |
| Rate for Payer: Aetna Commercial |
$29.21
|
| Rate for Payer: Cash Price |
$20.29
|
| Rate for Payer: Cigna All Commercial |
$29.18
|
| Rate for Payer: CORVEL All Commercial |
$31.44
|
| Rate for Payer: Coventry All Commercial |
$29.75
|
| Rate for Payer: Encore All Commercial |
$31.12
|
| Rate for Payer: Frontpath All Commercial |
$31.11
|
| Rate for Payer: Humana ChoiceCare |
$29.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.43
|
| Rate for Payer: PHCS All Commercial |
$25.36
|
| Rate for Payer: PHP All Commercial |
$25.64
|
| Rate for Payer: Sagamore Health Network All Products |
$26.10
|
| Rate for Payer: Signature Care EPO |
$28.06
|
| Rate for Payer: Signature Care PPO |
$29.75
|
| Rate for Payer: United Healthcare Commercial |
$26.64
|
|
|
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML ORAL SOLN
|
Facility
|
IP
|
$33.81
|
|
|
Service Code
|
NDC 00121231650
|
| Hospital Charge Code |
37848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.36 |
| Max. Negotiated Rate |
$31.44 |
| Rate for Payer: Aetna Commercial |
$29.21
|
| Rate for Payer: Cash Price |
$20.29
|
| Rate for Payer: Cigna All Commercial |
$29.18
|
| Rate for Payer: CORVEL All Commercial |
$31.44
|
| Rate for Payer: Coventry All Commercial |
$29.75
|
| Rate for Payer: Encore All Commercial |
$31.12
|
| Rate for Payer: Frontpath All Commercial |
$31.11
|
| Rate for Payer: Humana ChoiceCare |
$29.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.43
|
| Rate for Payer: PHCS All Commercial |
$25.36
|
| Rate for Payer: PHP All Commercial |
$25.64
|
| Rate for Payer: Sagamore Health Network All Products |
$26.10
|
| Rate for Payer: Signature Care EPO |
$28.06
|
| Rate for Payer: Signature Care PPO |
$29.75
|
| Rate for Payer: United Healthcare Commercial |
$26.64
|
|
|
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML ORAL SOLN
|
Facility
|
OP
|
$33.81
|
|
|
Service Code
|
NDC 00121231615
|
| Hospital Charge Code |
37848
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$31.44 |
| Rate for Payer: Aetna Commercial |
$28.54
|
| Rate for Payer: Aetna Medicare |
$10.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$19.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.90
|
| Rate for Payer: Cash Price |
$20.29
|
| Rate for Payer: Centivo All Commercial |
$18.39
|
| Rate for Payer: Cigna All Commercial |
$29.18
|
| Rate for Payer: CORVEL All Commercial |
$31.44
|
| Rate for Payer: Coventry All Commercial |
$29.75
|
| Rate for Payer: Encore All Commercial |
$31.12
|
| Rate for Payer: Frontpath All Commercial |
$31.11
|
| Rate for Payer: Humana ChoiceCare |
$29.20
|
| Rate for Payer: Humana Medicare |
$10.82
|
| Rate for Payer: Lucent All Commercial |
$18.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.43
|
| Rate for Payer: PHCS All Commercial |
$25.36
|
| Rate for Payer: PHP All Commercial |
$25.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.19
|
| Rate for Payer: Sagamore Health Network All Products |
$26.10
|
| Rate for Payer: Signature Care EPO |
$28.06
|
| Rate for Payer: Signature Care PPO |
$29.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.74
|
| Rate for Payer: United Healthcare Commercial |
$26.64
|
| Rate for Payer: United Healthcare Medicare |
$10.82
|
|
|
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML ORAL SOLN
|
Facility
|
OP
|
$33.81
|
|
|
Service Code
|
NDC 00121231650
|
| Hospital Charge Code |
37848
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$31.44 |
| Rate for Payer: Aetna Commercial |
$28.54
|
| Rate for Payer: Aetna Medicare |
$10.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$19.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.90
|
| Rate for Payer: Cash Price |
$20.29
|
| Rate for Payer: Centivo All Commercial |
$18.39
|
| Rate for Payer: Cigna All Commercial |
$29.18
|
| Rate for Payer: CORVEL All Commercial |
$31.44
|
| Rate for Payer: Coventry All Commercial |
$29.75
|
| Rate for Payer: Encore All Commercial |
$31.12
|
| Rate for Payer: Frontpath All Commercial |
$31.11
|
| Rate for Payer: Humana ChoiceCare |
$29.20
|
| Rate for Payer: Humana Medicare |
$10.82
|
| Rate for Payer: Lucent All Commercial |
$18.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.43
|
| Rate for Payer: PHCS All Commercial |
$25.36
|
| Rate for Payer: PHP All Commercial |
$25.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.19
|
| Rate for Payer: Sagamore Health Network All Products |
$26.10
|
| Rate for Payer: Signature Care EPO |
$28.06
|
| Rate for Payer: Signature Care PPO |
$29.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.74
|
| Rate for Payer: United Healthcare Commercial |
$26.64
|
| Rate for Payer: United Healthcare Medicare |
$10.82
|
|
|
HYDROCODONE-CHLORPHENIRAMINE 10-8 MG/5 ML ORAL SU12
|
Facility
|
IP
|
$16.10
|
|
|
Service Code
|
NDC 278080086
|
| Hospital Charge Code |
106413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.07 |
| Max. Negotiated Rate |
$14.97 |
| Rate for Payer: Aetna Commercial |
$13.91
|
| Rate for Payer: Cash Price |
$9.66
|
| Rate for Payer: Cigna All Commercial |
$13.89
|
| Rate for Payer: CORVEL All Commercial |
$14.97
|
| Rate for Payer: Coventry All Commercial |
$14.17
|
| Rate for Payer: Encore All Commercial |
$14.82
|
| Rate for Payer: Frontpath All Commercial |
$14.81
|
| Rate for Payer: Humana ChoiceCare |
$13.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.49
|
| Rate for Payer: PHCS All Commercial |
$12.07
|
| Rate for Payer: PHP All Commercial |
$12.21
|
| Rate for Payer: Sagamore Health Network All Products |
$12.43
|
| Rate for Payer: Signature Care EPO |
$13.36
|
| Rate for Payer: Signature Care PPO |
$14.17
|
| Rate for Payer: United Healthcare Commercial |
$12.69
|
|
|
HYDROCODONE-CHLORPHENIRAMINE 10-8 MG/5 ML ORAL SU12
|
Facility
|
IP
|
$317.40
|
|
|
Service Code
|
NDC 27808008601
|
| Hospital Charge Code |
106413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$238.05 |
| Max. Negotiated Rate |
$295.18 |
| Rate for Payer: Aetna Commercial |
$274.23
|
| Rate for Payer: Cash Price |
$190.44
|
| Rate for Payer: Cigna All Commercial |
$273.92
|
| Rate for Payer: CORVEL All Commercial |
$295.18
|
| Rate for Payer: Coventry All Commercial |
$279.31
|
| Rate for Payer: Encore All Commercial |
$292.17
|
| Rate for Payer: Frontpath All Commercial |
$292.01
|
| Rate for Payer: Humana ChoiceCare |
$274.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$285.66
|
| Rate for Payer: PHCS All Commercial |
$238.05
|
| Rate for Payer: PHP All Commercial |
$240.72
|
| Rate for Payer: Sagamore Health Network All Products |
$245.03
|
| Rate for Payer: Signature Care EPO |
$263.44
|
| Rate for Payer: Signature Care PPO |
$279.31
|
| Rate for Payer: United Healthcare Commercial |
$250.11
|
|
|
HYDROCODONE-CHLORPHENIRAMINE 10-8 MG/5 ML ORAL SU12
|
Facility
|
OP
|
$16.10
|
|
|
Service Code
|
NDC 278080086
|
| Hospital Charge Code |
106413
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.99 |
| Max. Negotiated Rate |
$14.97 |
| Rate for Payer: Aetna Commercial |
$13.59
|
| Rate for Payer: Aetna Medicare |
$5.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$9.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10.06
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.67
|
| Rate for Payer: Cash Price |
$9.66
|
| Rate for Payer: Centivo All Commercial |
$8.76
|
| Rate for Payer: Cigna All Commercial |
$13.89
|
| Rate for Payer: CORVEL All Commercial |
$14.97
|
| Rate for Payer: Coventry All Commercial |
$14.17
|
| Rate for Payer: Encore All Commercial |
$14.82
|
| Rate for Payer: Frontpath All Commercial |
$14.81
|
| Rate for Payer: Humana ChoiceCare |
$13.91
|
| Rate for Payer: Humana Medicare |
$5.15
|
| Rate for Payer: Lucent All Commercial |
$8.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.49
|
| Rate for Payer: PHCS All Commercial |
$12.07
|
| Rate for Payer: PHP All Commercial |
$12.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.28
|
| Rate for Payer: Sagamore Health Network All Products |
$12.43
|
| Rate for Payer: Signature Care EPO |
$13.36
|
| Rate for Payer: Signature Care PPO |
$14.17
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13.69
|
| Rate for Payer: United Healthcare Commercial |
$12.69
|
| Rate for Payer: United Healthcare Medicare |
$5.15
|
|
|
HYDROCODONE-CHLORPHENIRAMINE 10-8 MG/5 ML ORAL SU12
|
Facility
|
OP
|
$317.40
|
|
|
Service Code
|
NDC 27808008601
|
| Hospital Charge Code |
106413
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.39 |
| Max. Negotiated Rate |
$295.18 |
| Rate for Payer: Aetna Commercial |
$267.89
|
| Rate for Payer: Aetna Medicare |
$101.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$98.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$182.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$198.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$116.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$111.72
|
| Rate for Payer: Cash Price |
$190.44
|
| Rate for Payer: Centivo All Commercial |
$172.67
|
| Rate for Payer: Cigna All Commercial |
$273.92
|
| Rate for Payer: CORVEL All Commercial |
$295.18
|
| Rate for Payer: Coventry All Commercial |
$279.31
|
| Rate for Payer: Encore All Commercial |
$292.17
|
| Rate for Payer: Frontpath All Commercial |
$292.01
|
| Rate for Payer: Humana ChoiceCare |
$274.14
|
| Rate for Payer: Humana Medicare |
$101.57
|
| Rate for Payer: Lucent All Commercial |
$172.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$285.66
|
| Rate for Payer: PHCS All Commercial |
$238.05
|
| Rate for Payer: PHP All Commercial |
$240.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$123.79
|
| Rate for Payer: Sagamore Health Network All Products |
$245.03
|
| Rate for Payer: Signature Care EPO |
$263.44
|
| Rate for Payer: Signature Care PPO |
$279.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$269.79
|
| Rate for Payer: United Healthcare Commercial |
$250.11
|
| Rate for Payer: United Healthcare Medicare |
$101.57
|
|
|
HYDROCORTISONE 20 MG ORAL TAB
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Aetna Commercial |
$3.04
|
| Rate for Payer: Aetna Medicare |
$1.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.27
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Centivo All Commercial |
$1.96
|
| Rate for Payer: Cigna All Commercial |
$3.11
|
| Rate for Payer: CORVEL All Commercial |
$3.35
|
| Rate for Payer: Coventry All Commercial |
$3.17
|
| Rate for Payer: Encore All Commercial |
$3.31
|
| Rate for Payer: Frontpath All Commercial |
$3.31
|
| Rate for Payer: Humana ChoiceCare |
$3.11
|
| Rate for Payer: Humana Medicare |
$1.15
|
| Rate for Payer: Lucent All Commercial |
$1.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.24
|
| Rate for Payer: PHCS All Commercial |
$2.70
|
| Rate for Payer: PHP All Commercial |
$2.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.40
|
| Rate for Payer: Sagamore Health Network All Products |
$2.78
|
| Rate for Payer: Signature Care EPO |
$2.99
|
| Rate for Payer: Signature Care PPO |
$3.17
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.06
|
| Rate for Payer: United Healthcare Commercial |
$2.84
|
| Rate for Payer: United Healthcare Medicare |
$1.15
|
|
|
HYDROCORTISONE 20 MG ORAL TAB
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Aetna Commercial |
$3.11
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna All Commercial |
$3.11
|
| Rate for Payer: CORVEL All Commercial |
$3.35
|
| Rate for Payer: Coventry All Commercial |
$3.17
|
| Rate for Payer: Encore All Commercial |
$3.31
|
| Rate for Payer: Frontpath All Commercial |
$3.31
|
| Rate for Payer: Humana ChoiceCare |
$3.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.24
|
| Rate for Payer: PHCS All Commercial |
$2.70
|
| Rate for Payer: PHP All Commercial |
$2.73
|
| Rate for Payer: Sagamore Health Network All Products |
$2.78
|
| Rate for Payer: Signature Care EPO |
$2.99
|
| Rate for Payer: Signature Care PPO |
$3.17
|
| Rate for Payer: United Healthcare Commercial |
$2.84
|
|
|
HYDROCORTISONE 2.5 % TOP CREA
|
Facility
|
IP
|
$14.70
|
|
|
Service Code
|
NDC 00168008031
|
| Hospital Charge Code |
3727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.03 |
| Max. Negotiated Rate |
$13.67 |
| Rate for Payer: Aetna Commercial |
$12.70
|
| Rate for Payer: Cash Price |
$8.82
|
| Rate for Payer: Cigna All Commercial |
$12.69
|
| Rate for Payer: CORVEL All Commercial |
$13.67
|
| Rate for Payer: Coventry All Commercial |
$12.94
|
| Rate for Payer: Encore All Commercial |
$13.53
|
| Rate for Payer: Frontpath All Commercial |
$13.52
|
| Rate for Payer: Humana ChoiceCare |
$12.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.23
|
| Rate for Payer: PHCS All Commercial |
$11.03
|
| Rate for Payer: PHP All Commercial |
$11.15
|
| Rate for Payer: Sagamore Health Network All Products |
$11.35
|
| Rate for Payer: Signature Care EPO |
$12.20
|
| Rate for Payer: Signature Care PPO |
$12.94
|
| Rate for Payer: United Healthcare Commercial |
$11.58
|
|
|
HYDROCORTISONE 2.5 % TOP CREA
|
Facility
|
OP
|
$14.70
|
|
|
Service Code
|
NDC 00168008031
|
| Hospital Charge Code |
3727
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.56 |
| Max. Negotiated Rate |
$13.67 |
| Rate for Payer: Aetna Commercial |
$12.41
|
| Rate for Payer: Aetna Medicare |
$4.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$8.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.17
|
| Rate for Payer: Cash Price |
$8.82
|
| Rate for Payer: Centivo All Commercial |
$8.00
|
| Rate for Payer: Cigna All Commercial |
$12.69
|
| Rate for Payer: CORVEL All Commercial |
$13.67
|
| Rate for Payer: Coventry All Commercial |
$12.94
|
| Rate for Payer: Encore All Commercial |
$13.53
|
| Rate for Payer: Frontpath All Commercial |
$13.52
|
| Rate for Payer: Humana ChoiceCare |
$12.70
|
| Rate for Payer: Humana Medicare |
$4.70
|
| Rate for Payer: Lucent All Commercial |
$8.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.23
|
| Rate for Payer: PHCS All Commercial |
$11.03
|
| Rate for Payer: PHP All Commercial |
$11.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.73
|
| Rate for Payer: Sagamore Health Network All Products |
$11.35
|
| Rate for Payer: Signature Care EPO |
$12.20
|
| Rate for Payer: Signature Care PPO |
$12.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.49
|
| Rate for Payer: United Healthcare Commercial |
$11.58
|
| Rate for Payer: United Healthcare Medicare |
$4.70
|
|
|
HYDROCORTISONE 2.5 % TOP LOTN
|
Facility
|
IP
|
$50.80
|
|
|
Service Code
|
NDC 45802093716
|
| Hospital Charge Code |
3729
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.10 |
| Max. Negotiated Rate |
$47.24 |
| Rate for Payer: Aetna Commercial |
$43.89
|
| Rate for Payer: Cash Price |
$30.48
|
| Rate for Payer: Cigna All Commercial |
$43.84
|
| Rate for Payer: CORVEL All Commercial |
$47.24
|
| Rate for Payer: Coventry All Commercial |
$44.70
|
| Rate for Payer: Encore All Commercial |
$46.76
|
| Rate for Payer: Frontpath All Commercial |
$46.74
|
| Rate for Payer: Humana ChoiceCare |
$43.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.72
|
| Rate for Payer: PHCS All Commercial |
$38.10
|
| Rate for Payer: PHP All Commercial |
$38.53
|
| Rate for Payer: Sagamore Health Network All Products |
$39.22
|
| Rate for Payer: Signature Care EPO |
$42.16
|
| Rate for Payer: Signature Care PPO |
$44.70
|
| Rate for Payer: United Healthcare Commercial |
$40.03
|
|
|
HYDROCORTISONE 2.5 % TOP LOTN
|
Facility
|
OP
|
$50.80
|
|
|
Service Code
|
NDC 45802093716
|
| Hospital Charge Code |
3729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$47.24 |
| Rate for Payer: Aetna Commercial |
$42.87
|
| Rate for Payer: Aetna Medicare |
$16.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$29.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.75
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.88
|
| Rate for Payer: Cash Price |
$30.48
|
| Rate for Payer: Centivo All Commercial |
$27.63
|
| Rate for Payer: Cigna All Commercial |
$43.84
|
| Rate for Payer: CORVEL All Commercial |
$47.24
|
| Rate for Payer: Coventry All Commercial |
$44.70
|
| Rate for Payer: Encore All Commercial |
$46.76
|
| Rate for Payer: Frontpath All Commercial |
$46.74
|
| Rate for Payer: Humana ChoiceCare |
$43.88
|
| Rate for Payer: Humana Medicare |
$16.26
|
| Rate for Payer: Lucent All Commercial |
$27.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.72
|
| Rate for Payer: PHCS All Commercial |
$38.10
|
| Rate for Payer: PHP All Commercial |
$38.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.81
|
| Rate for Payer: Sagamore Health Network All Products |
$39.22
|
| Rate for Payer: Signature Care EPO |
$42.16
|
| Rate for Payer: Signature Care PPO |
$44.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$43.18
|
| Rate for Payer: United Healthcare Commercial |
$40.03
|
| Rate for Payer: United Healthcare Medicare |
$16.26
|
|
