|
HYDROCORTISONE 2.5 % TOP OINT
|
Facility
|
IP
|
$19.65
|
|
|
Service Code
|
NDC 00168014630
|
| Hospital Charge Code |
3732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.74 |
| Max. Negotiated Rate |
$18.27 |
| Rate for Payer: Aetna Commercial |
$16.98
|
| Rate for Payer: Cash Price |
$11.79
|
| Rate for Payer: Cigna All Commercial |
$16.96
|
| Rate for Payer: CORVEL All Commercial |
$18.27
|
| Rate for Payer: Coventry All Commercial |
$17.29
|
| Rate for Payer: Encore All Commercial |
$18.09
|
| Rate for Payer: Frontpath All Commercial |
$18.08
|
| Rate for Payer: Humana ChoiceCare |
$16.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.68
|
| Rate for Payer: PHCS All Commercial |
$14.74
|
| Rate for Payer: PHP All Commercial |
$14.90
|
| Rate for Payer: Sagamore Health Network All Products |
$15.17
|
| Rate for Payer: Signature Care EPO |
$16.31
|
| Rate for Payer: Signature Care PPO |
$17.29
|
| Rate for Payer: United Healthcare Commercial |
$15.48
|
|
|
HYDROCORTISONE 2.5 % TOP OINT
|
Facility
|
OP
|
$19.65
|
|
|
Service Code
|
NDC 00168014630
|
| Hospital Charge Code |
3732
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.09 |
| Max. Negotiated Rate |
$18.27 |
| Rate for Payer: Aetna Commercial |
$16.58
|
| Rate for Payer: Aetna Medicare |
$6.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$11.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.23
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.92
|
| Rate for Payer: Cash Price |
$11.79
|
| Rate for Payer: Centivo All Commercial |
$10.69
|
| Rate for Payer: Cigna All Commercial |
$16.96
|
| Rate for Payer: CORVEL All Commercial |
$18.27
|
| Rate for Payer: Coventry All Commercial |
$17.29
|
| Rate for Payer: Encore All Commercial |
$18.09
|
| Rate for Payer: Frontpath All Commercial |
$18.08
|
| Rate for Payer: Humana ChoiceCare |
$16.97
|
| Rate for Payer: Humana Medicare |
$6.29
|
| Rate for Payer: Lucent All Commercial |
$10.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.68
|
| Rate for Payer: PHCS All Commercial |
$14.74
|
| Rate for Payer: PHP All Commercial |
$14.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.66
|
| Rate for Payer: Sagamore Health Network All Products |
$15.17
|
| Rate for Payer: Signature Care EPO |
$16.31
|
| Rate for Payer: Signature Care PPO |
$17.29
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.70
|
| Rate for Payer: United Healthcare Commercial |
$15.48
|
| Rate for Payer: United Healthcare Medicare |
$6.29
|
|
|
HYDROCORTISONE ACETATE 25 MG RECT SUPP
|
Facility
|
OP
|
$10.93
|
|
|
Service Code
|
NDC 16571067621
|
| Hospital Charge Code |
3738
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.39 |
| Max. Negotiated Rate |
$10.16 |
| Rate for Payer: Aetna Commercial |
$9.22
|
| Rate for Payer: Aetna Medicare |
$3.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$6.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.85
|
| Rate for Payer: Cash Price |
$6.56
|
| Rate for Payer: Centivo All Commercial |
$5.94
|
| Rate for Payer: Cigna All Commercial |
$9.43
|
| Rate for Payer: CORVEL All Commercial |
$10.16
|
| Rate for Payer: Coventry All Commercial |
$9.62
|
| Rate for Payer: Encore All Commercial |
$10.06
|
| Rate for Payer: Frontpath All Commercial |
$10.05
|
| Rate for Payer: Humana ChoiceCare |
$9.44
|
| Rate for Payer: Humana Medicare |
$3.50
|
| Rate for Payer: Lucent All Commercial |
$5.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.83
|
| Rate for Payer: PHCS All Commercial |
$8.20
|
| Rate for Payer: PHP All Commercial |
$8.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.26
|
| Rate for Payer: Sagamore Health Network All Products |
$8.44
|
| Rate for Payer: Signature Care EPO |
$9.07
|
| Rate for Payer: Signature Care PPO |
$9.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9.29
|
| Rate for Payer: United Healthcare Commercial |
$8.61
|
| Rate for Payer: United Healthcare Medicare |
$3.50
|
|
|
HYDROCORTISONE ACETATE 25 MG RECT SUPP
|
Facility
|
IP
|
$10.93
|
|
|
Service Code
|
NDC 16571067621
|
| Hospital Charge Code |
3738
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.20 |
| Max. Negotiated Rate |
$10.16 |
| Rate for Payer: Aetna Commercial |
$9.44
|
| Rate for Payer: Cash Price |
$6.56
|
| Rate for Payer: Cigna All Commercial |
$9.43
|
| Rate for Payer: CORVEL All Commercial |
$10.16
|
| Rate for Payer: Coventry All Commercial |
$9.62
|
| Rate for Payer: Encore All Commercial |
$10.06
|
| Rate for Payer: Frontpath All Commercial |
$10.05
|
| Rate for Payer: Humana ChoiceCare |
$9.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.83
|
| Rate for Payer: PHCS All Commercial |
$8.20
|
| Rate for Payer: PHP All Commercial |
$8.29
|
| Rate for Payer: Sagamore Health Network All Products |
$8.44
|
| Rate for Payer: Signature Care EPO |
$9.07
|
| Rate for Payer: Signature Care PPO |
$9.62
|
| Rate for Payer: United Healthcare Commercial |
$8.61
|
|
|
HYDROCORTISONE-ALOE VERA 1 % TOP CREA
|
Facility
|
IP
|
$10.39
|
|
|
Service Code
|
NDC 00536140795
|
| Hospital Charge Code |
14190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.79 |
| Max. Negotiated Rate |
$9.66 |
| Rate for Payer: Aetna Commercial |
$8.98
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Cigna All Commercial |
$8.96
|
| Rate for Payer: CORVEL All Commercial |
$9.66
|
| Rate for Payer: Coventry All Commercial |
$9.14
|
| Rate for Payer: Encore All Commercial |
$9.56
|
| Rate for Payer: Frontpath All Commercial |
$9.56
|
| Rate for Payer: Humana ChoiceCare |
$8.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.35
|
| Rate for Payer: PHCS All Commercial |
$7.79
|
| Rate for Payer: PHP All Commercial |
$7.88
|
| Rate for Payer: Sagamore Health Network All Products |
$8.02
|
| Rate for Payer: Signature Care EPO |
$8.62
|
| Rate for Payer: Signature Care PPO |
$9.14
|
| Rate for Payer: United Healthcare Commercial |
$8.19
|
|
|
HYDROCORTISONE-ALOE VERA 1 % TOP CREA
|
Facility
|
OP
|
$10.39
|
|
|
Service Code
|
NDC 00536140795
|
| Hospital Charge Code |
14190
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.22 |
| Max. Negotiated Rate |
$9.66 |
| Rate for Payer: Aetna Commercial |
$8.77
|
| Rate for Payer: Aetna Medicare |
$3.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.49
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.66
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: Centivo All Commercial |
$5.65
|
| Rate for Payer: Cigna All Commercial |
$8.96
|
| Rate for Payer: CORVEL All Commercial |
$9.66
|
| Rate for Payer: Coventry All Commercial |
$9.14
|
| Rate for Payer: Encore All Commercial |
$9.56
|
| Rate for Payer: Frontpath All Commercial |
$9.56
|
| Rate for Payer: Humana ChoiceCare |
$8.97
|
| Rate for Payer: Humana Medicare |
$3.32
|
| Rate for Payer: Lucent All Commercial |
$5.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.35
|
| Rate for Payer: PHCS All Commercial |
$7.79
|
| Rate for Payer: PHP All Commercial |
$7.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.05
|
| Rate for Payer: Sagamore Health Network All Products |
$8.02
|
| Rate for Payer: Signature Care EPO |
$8.62
|
| Rate for Payer: Signature Care PPO |
$9.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.83
|
| Rate for Payer: United Healthcare Commercial |
$8.19
|
| Rate for Payer: United Healthcare Medicare |
$3.32
|
|
|
HYDROCORTISONE-PRAMOXINE 2.5-1 % RECT CREA
|
Facility
|
OP
|
$580.80
|
|
|
Service Code
|
NDC 45802047264
|
| Hospital Charge Code |
28848
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.05 |
| Max. Negotiated Rate |
$540.14 |
| Rate for Payer: Aetna Commercial |
$490.20
|
| Rate for Payer: Aetna Medicare |
$185.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$180.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$333.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$363.06
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$213.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$204.44
|
| Rate for Payer: Cash Price |
$348.48
|
| Rate for Payer: Centivo All Commercial |
$315.96
|
| Rate for Payer: Cigna All Commercial |
$501.23
|
| Rate for Payer: CORVEL All Commercial |
$540.14
|
| Rate for Payer: Coventry All Commercial |
$511.10
|
| Rate for Payer: Encore All Commercial |
$534.63
|
| Rate for Payer: Frontpath All Commercial |
$534.34
|
| Rate for Payer: Humana ChoiceCare |
$501.64
|
| Rate for Payer: Humana Medicare |
$185.86
|
| Rate for Payer: Lucent All Commercial |
$315.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$522.72
|
| Rate for Payer: PHCS All Commercial |
$435.60
|
| Rate for Payer: PHP All Commercial |
$440.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$226.51
|
| Rate for Payer: Sagamore Health Network All Products |
$448.38
|
| Rate for Payer: Signature Care EPO |
$482.06
|
| Rate for Payer: Signature Care PPO |
$511.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$493.68
|
| Rate for Payer: United Healthcare Commercial |
$457.67
|
| Rate for Payer: United Healthcare Medicare |
$185.86
|
|
|
HYDROCORTISONE-PRAMOXINE 2.5-1 % RECT CREA
|
Facility
|
IP
|
$580.80
|
|
|
Service Code
|
NDC 45802047264
|
| Hospital Charge Code |
28848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$435.60 |
| Max. Negotiated Rate |
$540.14 |
| Rate for Payer: Aetna Commercial |
$501.81
|
| Rate for Payer: Cash Price |
$348.48
|
| Rate for Payer: Cigna All Commercial |
$501.23
|
| Rate for Payer: CORVEL All Commercial |
$540.14
|
| Rate for Payer: Coventry All Commercial |
$511.10
|
| Rate for Payer: Encore All Commercial |
$534.63
|
| Rate for Payer: Frontpath All Commercial |
$534.34
|
| Rate for Payer: Humana ChoiceCare |
$501.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$522.72
|
| Rate for Payer: PHCS All Commercial |
$435.60
|
| Rate for Payer: PHP All Commercial |
$440.48
|
| Rate for Payer: Sagamore Health Network All Products |
$448.38
|
| Rate for Payer: Signature Care EPO |
$482.06
|
| Rate for Payer: Signature Care PPO |
$511.10
|
| Rate for Payer: United Healthcare Commercial |
$457.67
|
|
|
HYDROCORTISONE SOD SUCCINATE 100 MG INJ SOLR
|
Facility
|
IP
|
$120.47
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
111163
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.35 |
| Max. Negotiated Rate |
$112.04 |
| Rate for Payer: Aetna Commercial |
$104.09
|
| Rate for Payer: Cash Price |
$72.28
|
| Rate for Payer: Cigna All Commercial |
$103.97
|
| Rate for Payer: CORVEL All Commercial |
$112.04
|
| Rate for Payer: Coventry All Commercial |
$106.01
|
| Rate for Payer: Encore All Commercial |
$110.89
|
| Rate for Payer: Frontpath All Commercial |
$110.83
|
| Rate for Payer: Humana ChoiceCare |
$104.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$108.42
|
| Rate for Payer: PHCS All Commercial |
$90.35
|
| Rate for Payer: PHP All Commercial |
$91.36
|
| Rate for Payer: Sagamore Health Network All Products |
$93.00
|
| Rate for Payer: Signature Care EPO |
$99.99
|
| Rate for Payer: Signature Care PPO |
$106.01
|
| Rate for Payer: United Healthcare Commercial |
$94.93
|
|
|
HYDROCORTISONE SOD SUCCINATE 100 MG INJ SOLR
|
Facility
|
OP
|
$120.47
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
111163
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.35 |
| Max. Negotiated Rate |
$112.04 |
| Rate for Payer: Aetna Commercial |
$101.68
|
| Rate for Payer: Aetna Medicare |
$38.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$37.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$69.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$75.31
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$44.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$42.41
|
| Rate for Payer: Cash Price |
$72.28
|
| Rate for Payer: Centivo All Commercial |
$65.54
|
| Rate for Payer: Cigna All Commercial |
$103.97
|
| Rate for Payer: CORVEL All Commercial |
$112.04
|
| Rate for Payer: Coventry All Commercial |
$106.01
|
| Rate for Payer: Encore All Commercial |
$110.89
|
| Rate for Payer: Frontpath All Commercial |
$110.83
|
| Rate for Payer: Humana ChoiceCare |
$104.05
|
| Rate for Payer: Humana Medicare |
$38.55
|
| Rate for Payer: Lucent All Commercial |
$65.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$108.42
|
| Rate for Payer: PHCS All Commercial |
$90.35
|
| Rate for Payer: PHP All Commercial |
$91.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$46.98
|
| Rate for Payer: Sagamore Health Network All Products |
$93.00
|
| Rate for Payer: Signature Care EPO |
$99.99
|
| Rate for Payer: Signature Care PPO |
$106.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$102.40
|
| Rate for Payer: United Healthcare Commercial |
$94.93
|
| Rate for Payer: United Healthcare Medicare |
$38.55
|
|
|
HYDROCORTISONE SOD SUCC (PF) 250 MG/2 ML INJ SOLR
|
Facility
|
IP
|
$285.04
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
121170
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$213.78 |
| Max. Negotiated Rate |
$265.09 |
| Rate for Payer: Aetna Commercial |
$246.27
|
| Rate for Payer: Cash Price |
$171.02
|
| Rate for Payer: Cigna All Commercial |
$245.99
|
| Rate for Payer: CORVEL All Commercial |
$265.09
|
| Rate for Payer: Coventry All Commercial |
$250.84
|
| Rate for Payer: Encore All Commercial |
$262.38
|
| Rate for Payer: Frontpath All Commercial |
$262.24
|
| Rate for Payer: Humana ChoiceCare |
$246.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$256.54
|
| Rate for Payer: PHCS All Commercial |
$213.78
|
| Rate for Payer: PHP All Commercial |
$216.17
|
| Rate for Payer: Sagamore Health Network All Products |
$220.05
|
| Rate for Payer: Signature Care EPO |
$236.58
|
| Rate for Payer: Signature Care PPO |
$250.84
|
| Rate for Payer: United Healthcare Commercial |
$224.61
|
|
|
HYDROCORTISONE SOD SUCC (PF) 250 MG/2 ML INJ SOLR
|
Facility
|
OP
|
$285.04
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
121170
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.36 |
| Max. Negotiated Rate |
$265.09 |
| Rate for Payer: Aetna Commercial |
$240.57
|
| Rate for Payer: Aetna Medicare |
$91.21
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$88.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$163.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$178.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$104.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$100.33
|
| Rate for Payer: Cash Price |
$171.02
|
| Rate for Payer: Centivo All Commercial |
$155.06
|
| Rate for Payer: Cigna All Commercial |
$245.99
|
| Rate for Payer: CORVEL All Commercial |
$265.09
|
| Rate for Payer: Coventry All Commercial |
$250.84
|
| Rate for Payer: Encore All Commercial |
$262.38
|
| Rate for Payer: Frontpath All Commercial |
$262.24
|
| Rate for Payer: Humana ChoiceCare |
$246.19
|
| Rate for Payer: Humana Medicare |
$91.21
|
| Rate for Payer: Lucent All Commercial |
$155.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$256.54
|
| Rate for Payer: PHCS All Commercial |
$213.78
|
| Rate for Payer: PHP All Commercial |
$216.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$111.17
|
| Rate for Payer: Sagamore Health Network All Products |
$220.05
|
| Rate for Payer: Signature Care EPO |
$236.58
|
| Rate for Payer: Signature Care PPO |
$250.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$242.28
|
| Rate for Payer: United Healthcare Commercial |
$224.61
|
| Rate for Payer: United Healthcare Medicare |
$91.21
|
|
|
HYDROGEN PEROXIDE 3 % MISC SOLN
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 21599034562
|
| Hospital Charge Code |
3752
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
|
|
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG
|
Facility
|
OP
|
$18.23
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
164910
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$16.95 |
| Rate for Payer: Aetna Commercial |
$15.38
|
| Rate for Payer: Aetna Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.39
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.42
|
| Rate for Payer: Cash Price |
$10.94
|
| Rate for Payer: Centivo All Commercial |
$9.92
|
| Rate for Payer: Cigna All Commercial |
$15.73
|
| Rate for Payer: CORVEL All Commercial |
$16.95
|
| Rate for Payer: Coventry All Commercial |
$16.04
|
| Rate for Payer: Encore All Commercial |
$16.78
|
| Rate for Payer: Frontpath All Commercial |
$16.77
|
| Rate for Payer: Humana ChoiceCare |
$15.74
|
| Rate for Payer: Humana Medicare |
$5.83
|
| Rate for Payer: Lucent All Commercial |
$9.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.41
|
| Rate for Payer: PHCS All Commercial |
$13.67
|
| Rate for Payer: PHP All Commercial |
$13.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.11
|
| Rate for Payer: Sagamore Health Network All Products |
$14.07
|
| Rate for Payer: Signature Care EPO |
$15.13
|
| Rate for Payer: Signature Care PPO |
$16.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.49
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
| Rate for Payer: United Healthcare Medicare |
$5.83
|
|
|
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG
|
Facility
|
IP
|
$18.23
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
164910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.67 |
| Max. Negotiated Rate |
$16.95 |
| Rate for Payer: Aetna Commercial |
$15.75
|
| Rate for Payer: Cash Price |
$10.94
|
| Rate for Payer: Cigna All Commercial |
$15.73
|
| Rate for Payer: CORVEL All Commercial |
$16.95
|
| Rate for Payer: Coventry All Commercial |
$16.04
|
| Rate for Payer: Encore All Commercial |
$16.78
|
| Rate for Payer: Frontpath All Commercial |
$16.77
|
| Rate for Payer: Humana ChoiceCare |
$15.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.41
|
| Rate for Payer: PHCS All Commercial |
$13.67
|
| Rate for Payer: PHP All Commercial |
$13.82
|
| Rate for Payer: Sagamore Health Network All Products |
$14.07
|
| Rate for Payer: Signature Care EPO |
$15.13
|
| Rate for Payer: Signature Care PPO |
$16.04
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
|
|
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG S.O. (CAMERON)
|
Facility
|
IP
|
$18.23
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
140180106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.67 |
| Max. Negotiated Rate |
$16.95 |
| Rate for Payer: Aetna Commercial |
$15.75
|
| Rate for Payer: Cash Price |
$10.94
|
| Rate for Payer: Cigna All Commercial |
$15.73
|
| Rate for Payer: CORVEL All Commercial |
$16.95
|
| Rate for Payer: Coventry All Commercial |
$16.04
|
| Rate for Payer: Encore All Commercial |
$16.78
|
| Rate for Payer: Frontpath All Commercial |
$16.77
|
| Rate for Payer: Humana ChoiceCare |
$15.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.41
|
| Rate for Payer: PHCS All Commercial |
$13.67
|
| Rate for Payer: PHP All Commercial |
$13.82
|
| Rate for Payer: Sagamore Health Network All Products |
$14.07
|
| Rate for Payer: Signature Care EPO |
$15.13
|
| Rate for Payer: Signature Care PPO |
$16.04
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
|
|
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG S.O. (CAMERON)
|
Facility
|
OP
|
$18.23
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
140180106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$16.95 |
| Rate for Payer: Aetna Commercial |
$15.38
|
| Rate for Payer: Aetna Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.39
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.42
|
| Rate for Payer: Cash Price |
$10.94
|
| Rate for Payer: Centivo All Commercial |
$9.92
|
| Rate for Payer: Cigna All Commercial |
$15.73
|
| Rate for Payer: CORVEL All Commercial |
$16.95
|
| Rate for Payer: Coventry All Commercial |
$16.04
|
| Rate for Payer: Encore All Commercial |
$16.78
|
| Rate for Payer: Frontpath All Commercial |
$16.77
|
| Rate for Payer: Humana ChoiceCare |
$15.74
|
| Rate for Payer: Humana Medicare |
$5.83
|
| Rate for Payer: Lucent All Commercial |
$9.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.41
|
| Rate for Payer: PHCS All Commercial |
$13.67
|
| Rate for Payer: PHP All Commercial |
$13.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.11
|
| Rate for Payer: Sagamore Health Network All Products |
$14.07
|
| Rate for Payer: Signature Care EPO |
$15.13
|
| Rate for Payer: Signature Care PPO |
$16.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.49
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
| Rate for Payer: United Healthcare Medicare |
$5.83
|
|
|
HYDROMORPHONE 1 MG/ML INJ S.O.
|
Facility
|
IP
|
$28.29
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
408114223
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.22 |
| Max. Negotiated Rate |
$26.31 |
| Rate for Payer: Aetna Commercial |
$24.44
|
| Rate for Payer: Aetna Commercial |
$19.31
|
| Rate for Payer: Cash Price |
$13.41
|
| Rate for Payer: Cash Price |
$16.97
|
| Rate for Payer: Cigna All Commercial |
$19.28
|
| Rate for Payer: Cigna All Commercial |
$24.41
|
| Rate for Payer: CORVEL All Commercial |
$20.78
|
| Rate for Payer: CORVEL All Commercial |
$26.31
|
| Rate for Payer: Coventry All Commercial |
$24.89
|
| Rate for Payer: Coventry All Commercial |
$19.66
|
| Rate for Payer: Encore All Commercial |
$26.04
|
| Rate for Payer: Encore All Commercial |
$20.57
|
| Rate for Payer: Frontpath All Commercial |
$20.56
|
| Rate for Payer: Frontpath All Commercial |
$26.02
|
| Rate for Payer: Humana ChoiceCare |
$19.30
|
| Rate for Payer: Humana ChoiceCare |
$24.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.46
|
| Rate for Payer: PHCS All Commercial |
$21.22
|
| Rate for Payer: PHCS All Commercial |
$16.76
|
| Rate for Payer: PHP All Commercial |
$16.95
|
| Rate for Payer: PHP All Commercial |
$21.45
|
| Rate for Payer: Sagamore Health Network All Products |
$21.84
|
| Rate for Payer: Sagamore Health Network All Products |
$17.25
|
| Rate for Payer: Signature Care EPO |
$23.48
|
| Rate for Payer: Signature Care EPO |
$18.55
|
| Rate for Payer: Signature Care PPO |
$19.66
|
| Rate for Payer: Signature Care PPO |
$24.89
|
| Rate for Payer: United Healthcare Commercial |
$17.61
|
| Rate for Payer: United Healthcare Commercial |
$22.29
|
|
|
HYDROMORPHONE 1 MG/ML INJ S.O.
|
Facility
|
OP
|
$28.29
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
408114223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$26.31 |
| Rate for Payer: Aetna Commercial |
$23.87
|
| Rate for Payer: Aetna Commercial |
$18.86
|
| Rate for Payer: Aetna Medicare |
$7.15
|
| Rate for Payer: Aetna Medicare |
$9.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$12.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.96
|
| Rate for Payer: Cash Price |
$16.97
|
| Rate for Payer: Cash Price |
$13.41
|
| Rate for Payer: Centivo All Commercial |
$15.39
|
| Rate for Payer: Centivo All Commercial |
$12.16
|
| Rate for Payer: Cigna All Commercial |
$19.28
|
| Rate for Payer: Cigna All Commercial |
$24.41
|
| Rate for Payer: CORVEL All Commercial |
$20.78
|
| Rate for Payer: CORVEL All Commercial |
$26.31
|
| Rate for Payer: Coventry All Commercial |
$19.66
|
| Rate for Payer: Coventry All Commercial |
$24.89
|
| Rate for Payer: Encore All Commercial |
$20.57
|
| Rate for Payer: Encore All Commercial |
$26.04
|
| Rate for Payer: Frontpath All Commercial |
$26.02
|
| Rate for Payer: Frontpath All Commercial |
$20.56
|
| Rate for Payer: Humana ChoiceCare |
$24.43
|
| Rate for Payer: Humana ChoiceCare |
$19.30
|
| Rate for Payer: Humana Medicare |
$9.05
|
| Rate for Payer: Humana Medicare |
$7.15
|
| Rate for Payer: Lucent All Commercial |
$12.16
|
| Rate for Payer: Lucent All Commercial |
$15.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.11
|
| Rate for Payer: PHCS All Commercial |
$21.22
|
| Rate for Payer: PHCS All Commercial |
$16.76
|
| Rate for Payer: PHP All Commercial |
$16.95
|
| Rate for Payer: PHP All Commercial |
$21.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.03
|
| Rate for Payer: Sagamore Health Network All Products |
$17.25
|
| Rate for Payer: Sagamore Health Network All Products |
$21.84
|
| Rate for Payer: Signature Care EPO |
$23.48
|
| Rate for Payer: Signature Care EPO |
$18.55
|
| Rate for Payer: Signature Care PPO |
$19.66
|
| Rate for Payer: Signature Care PPO |
$24.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.99
|
| Rate for Payer: United Healthcare Commercial |
$17.61
|
| Rate for Payer: United Healthcare Commercial |
$22.29
|
| Rate for Payer: United Healthcare Medicare |
$7.15
|
| Rate for Payer: United Healthcare Medicare |
$9.05
|
|
|
HYDROMORPHONE 1 MG/ML INJ SYRG
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
114223
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
HYDROMORPHONE 1 MG/ML INJ SYRG
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
114223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
HYDROMORPHONE 2 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 42858030101
|
| Hospital Charge Code |
3760
|
|
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
|
|
|
HYDROMORPHONE 2 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 42858030101
|
| Hospital Charge Code |
3760
|
|
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
|
|
|
HYDROMORPHONE 4 MG ORAL TAB
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 42858030201
|
| Hospital Charge Code |
3761
|
|
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
|
|
|
HYDROMORPHONE 4 MG ORAL TAB
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 42858030201
|
| Hospital Charge Code |
3761
|
|
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
|
|
