|
HYDROMORPHONE 6 MG/30 ML (0.2 MG/ML) PCA (CAMERON)
|
Facility
|
IP
|
$104.58
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.44 |
| Max. Negotiated Rate |
$97.26 |
| Rate for Payer: Aetna Commercial |
$90.36
|
| Rate for Payer: Cash Price |
$62.75
|
| Rate for Payer: Cigna All Commercial |
$90.25
|
| Rate for Payer: CORVEL All Commercial |
$97.26
|
| Rate for Payer: Coventry All Commercial |
$92.03
|
| Rate for Payer: Encore All Commercial |
$96.27
|
| Rate for Payer: Frontpath All Commercial |
$96.21
|
| Rate for Payer: Humana ChoiceCare |
$90.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$94.12
|
| Rate for Payer: PHCS All Commercial |
$78.44
|
| Rate for Payer: PHP All Commercial |
$79.31
|
| Rate for Payer: Sagamore Health Network All Products |
$80.74
|
| Rate for Payer: Signature Care EPO |
$86.80
|
| Rate for Payer: Signature Care PPO |
$92.03
|
| Rate for Payer: United Healthcare Commercial |
$82.41
|
|
|
HYDROMORPHONE 6 MG/30 ML (0.2 MG/ML) PCA (CAMERON)
|
Facility
|
OP
|
$104.58
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
1.401E+12
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.42 |
| Max. Negotiated Rate |
$97.26 |
| Rate for Payer: Aetna Commercial |
$88.27
|
| Rate for Payer: Aetna Medicare |
$33.47
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$32.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$60.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$65.37
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$38.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.81
|
| Rate for Payer: Cash Price |
$62.75
|
| Rate for Payer: Centivo All Commercial |
$56.89
|
| Rate for Payer: Cigna All Commercial |
$90.25
|
| Rate for Payer: CORVEL All Commercial |
$97.26
|
| Rate for Payer: Coventry All Commercial |
$92.03
|
| Rate for Payer: Encore All Commercial |
$96.27
|
| Rate for Payer: Frontpath All Commercial |
$96.21
|
| Rate for Payer: Humana ChoiceCare |
$90.33
|
| Rate for Payer: Humana Medicare |
$33.47
|
| Rate for Payer: Lucent All Commercial |
$56.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$94.12
|
| Rate for Payer: PHCS All Commercial |
$78.44
|
| Rate for Payer: PHP All Commercial |
$79.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.79
|
| Rate for Payer: Sagamore Health Network All Products |
$80.74
|
| Rate for Payer: Signature Care EPO |
$86.80
|
| Rate for Payer: Signature Care PPO |
$92.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$88.89
|
| Rate for Payer: United Healthcare Commercial |
$82.41
|
| Rate for Payer: United Healthcare Medicare |
$33.47
|
|
|
HYDROMORPHONE (PF) 0.2 MG/ML INJ SYRG
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
191308
|
|
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 (PF) 0.2 MG/ML INJ SYRG
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
191308
|
|
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 (PF) 0.5 MG/0.5 ML INJ SYRG
|
Facility
|
IP
|
$29.04
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
180106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.78 |
| Max. Negotiated Rate |
$27.01 |
| Rate for Payer: Aetna Commercial |
$25.09
|
| Rate for Payer: Cash Price |
$17.43
|
| Rate for Payer: Cigna All Commercial |
$25.06
|
| Rate for Payer: CORVEL All Commercial |
$27.01
|
| Rate for Payer: Coventry All Commercial |
$25.56
|
| Rate for Payer: Encore All Commercial |
$26.73
|
| Rate for Payer: Frontpath All Commercial |
$26.72
|
| Rate for Payer: Humana ChoiceCare |
$25.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.14
|
| Rate for Payer: PHCS All Commercial |
$21.78
|
| Rate for Payer: PHP All Commercial |
$22.03
|
| Rate for Payer: Sagamore Health Network All Products |
$22.42
|
| Rate for Payer: Signature Care EPO |
$24.11
|
| Rate for Payer: Signature Care PPO |
$25.56
|
| Rate for Payer: United Healthcare Commercial |
$22.89
|
|
|
HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJ SYRG
|
Facility
|
OP
|
$29.04
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
180106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$27.01 |
| Rate for Payer: Aetna Commercial |
$24.51
|
| Rate for Payer: Aetna Medicare |
$9.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$16.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.22
|
| Rate for Payer: Cash Price |
$17.43
|
| Rate for Payer: Centivo All Commercial |
$15.80
|
| Rate for Payer: Cigna All Commercial |
$25.06
|
| Rate for Payer: CORVEL All Commercial |
$27.01
|
| Rate for Payer: Coventry All Commercial |
$25.56
|
| Rate for Payer: Encore All Commercial |
$26.73
|
| Rate for Payer: Frontpath All Commercial |
$26.72
|
| Rate for Payer: Humana ChoiceCare |
$25.08
|
| Rate for Payer: Humana Medicare |
$9.29
|
| Rate for Payer: Lucent All Commercial |
$15.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$26.14
|
| Rate for Payer: PHCS All Commercial |
$21.78
|
| Rate for Payer: PHP All Commercial |
$22.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.33
|
| Rate for Payer: Sagamore Health Network All Products |
$22.42
|
| Rate for Payer: Signature Care EPO |
$24.11
|
| Rate for Payer: Signature Care PPO |
$25.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.69
|
| Rate for Payer: United Healthcare Commercial |
$22.89
|
| Rate for Payer: United Healthcare Medicare |
$9.29
|
|
|
HYDROMORPHONE (PF)-0.9 % NACL 6 MG/30 ML (0.2 MG/ML) IV SPCA
|
Facility
|
OP
|
$58.80
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
157003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.23 |
| Max. Negotiated Rate |
$54.68 |
| Rate for Payer: Aetna Commercial |
$49.63
|
| Rate for Payer: Aetna Medicare |
$18.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$18.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$33.77
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$36.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.70
|
| Rate for Payer: Cash Price |
$35.28
|
| Rate for Payer: Centivo All Commercial |
$31.99
|
| Rate for Payer: Cigna All Commercial |
$50.74
|
| Rate for Payer: CORVEL All Commercial |
$54.68
|
| Rate for Payer: Coventry All Commercial |
$51.74
|
| Rate for Payer: Encore All Commercial |
$54.13
|
| Rate for Payer: Frontpath All Commercial |
$54.10
|
| Rate for Payer: Humana ChoiceCare |
$50.79
|
| Rate for Payer: Humana Medicare |
$18.82
|
| Rate for Payer: Lucent All Commercial |
$31.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$52.92
|
| Rate for Payer: PHCS All Commercial |
$44.10
|
| Rate for Payer: PHP All Commercial |
$44.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.93
|
| Rate for Payer: Sagamore Health Network All Products |
$45.39
|
| Rate for Payer: Signature Care EPO |
$48.80
|
| Rate for Payer: Signature Care PPO |
$51.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$49.98
|
| Rate for Payer: United Healthcare Commercial |
$46.33
|
| Rate for Payer: United Healthcare Medicare |
$18.82
|
|
|
HYDROMORPHONE (PF)-0.9 % NACL 6 MG/30 ML (0.2 MG/ML) IV SPCA
|
Facility
|
IP
|
$58.80
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
157003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$54.68 |
| Rate for Payer: Aetna Commercial |
$50.80
|
| Rate for Payer: Cash Price |
$35.28
|
| Rate for Payer: Cigna All Commercial |
$50.74
|
| Rate for Payer: CORVEL All Commercial |
$54.68
|
| Rate for Payer: Coventry All Commercial |
$51.74
|
| Rate for Payer: Encore All Commercial |
$54.13
|
| Rate for Payer: Frontpath All Commercial |
$54.10
|
| Rate for Payer: Humana ChoiceCare |
$50.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$52.92
|
| Rate for Payer: PHCS All Commercial |
$44.10
|
| Rate for Payer: PHP All Commercial |
$44.59
|
| Rate for Payer: Sagamore Health Network All Products |
$45.39
|
| Rate for Payer: Signature Care EPO |
$48.80
|
| Rate for Payer: Signature Care PPO |
$51.74
|
| Rate for Payer: United Healthcare Commercial |
$46.33
|
|
|
HYDROMORPHONE (PF) 1 MG/ML INJ SOLN
|
Facility
|
OP
|
$28.29
|
|
|
Service Code
|
NDC 63323085203
|
| Hospital Charge Code |
110971
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$26.31 |
| Rate for Payer: Aetna Commercial |
$23.87
|
| Rate for Payer: Aetna Medicare |
$9.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| 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 Traditional |
$17.68
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.96
|
| Rate for Payer: Cash Price |
$16.97
|
| Rate for Payer: Cash Price |
$16.97
|
| Rate for Payer: Centivo All Commercial |
$15.39
|
| Rate for Payer: Cigna All Commercial |
$24.41
|
| Rate for Payer: CORVEL All Commercial |
$26.31
|
| Rate for Payer: Coventry All Commercial |
$24.89
|
| Rate for Payer: Encore All Commercial |
$26.04
|
| Rate for Payer: Frontpath All Commercial |
$26.02
|
| Rate for Payer: Humana ChoiceCare |
$24.43
|
| Rate for Payer: Humana Medicare |
$9.05
|
| Rate for Payer: Lucent All Commercial |
$15.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.46
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$21.22
|
| Rate for Payer: PHP All Commercial |
$21.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.03
|
| Rate for Payer: Sagamore Health Network All Products |
$21.84
|
| Rate for Payer: Signature Care EPO |
$23.48
|
| Rate for Payer: Signature Care PPO |
$24.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.04
|
| Rate for Payer: United Healthcare Commercial |
$22.29
|
| Rate for Payer: United Healthcare Medicare |
$9.05
|
|
|
HYDROMORPHONE (PF) 1 MG/ML INJ SOLN
|
Facility
|
IP
|
$28.29
|
|
|
Service Code
|
NDC 63323085203
|
| Hospital Charge Code |
110971
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.22 |
| Max. Negotiated Rate |
$26.31 |
| Rate for Payer: Aetna Commercial |
$24.44
|
| Rate for Payer: Cash Price |
$16.97
|
| Rate for Payer: Cigna All Commercial |
$24.41
|
| Rate for Payer: CORVEL All Commercial |
$26.31
|
| Rate for Payer: Coventry All Commercial |
$24.89
|
| Rate for Payer: Encore All Commercial |
$26.04
|
| Rate for Payer: Frontpath All Commercial |
$26.02
|
| Rate for Payer: Humana ChoiceCare |
$24.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.46
|
| Rate for Payer: PHCS All Commercial |
$21.22
|
| Rate for Payer: PHP All Commercial |
$21.45
|
| Rate for Payer: Sagamore Health Network All Products |
$21.84
|
| Rate for Payer: Signature Care EPO |
$23.48
|
| Rate for Payer: Signature Care PPO |
$24.89
|
| Rate for Payer: United Healthcare Commercial |
$22.29
|
|
|
HYDROMORPHONE (PF) 1 MG/ML INJ SYRG
|
Facility
|
OP
|
$22.34
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
3757
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$20.78 |
| Rate for Payer: Aetna Commercial |
$18.86
|
| Rate for Payer: Aetna Medicare |
$7.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.93
|
| 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: CareSource Indiana of IN Just 4 Me |
$8.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.87
|
| Rate for Payer: Cash Price |
$13.41
|
| Rate for Payer: Centivo All Commercial |
$12.16
|
| Rate for Payer: Cigna All Commercial |
$19.28
|
| Rate for Payer: CORVEL All Commercial |
$20.78
|
| Rate for Payer: Coventry All Commercial |
$19.66
|
| Rate for Payer: Encore All Commercial |
$20.57
|
| Rate for Payer: Frontpath All Commercial |
$20.56
|
| Rate for Payer: Humana ChoiceCare |
$19.30
|
| Rate for Payer: Humana Medicare |
$7.15
|
| Rate for Payer: Lucent All Commercial |
$12.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.11
|
| Rate for Payer: PHCS All Commercial |
$16.76
|
| Rate for Payer: PHP All Commercial |
$16.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.71
|
| Rate for Payer: Sagamore Health Network All Products |
$17.25
|
| Rate for Payer: Signature Care EPO |
$18.55
|
| Rate for Payer: Signature Care PPO |
$19.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.99
|
| Rate for Payer: United Healthcare Commercial |
$17.61
|
| Rate for Payer: United Healthcare Medicare |
$7.15
|
|
|
HYDROMORPHONE (PF) 1 MG/ML INJ SYRG
|
Facility
|
IP
|
$22.34
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
3757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.76 |
| Max. Negotiated Rate |
$20.78 |
| Rate for Payer: Aetna Commercial |
$19.31
|
| Rate for Payer: Cash Price |
$13.41
|
| Rate for Payer: Cigna All Commercial |
$19.28
|
| Rate for Payer: CORVEL All Commercial |
$20.78
|
| Rate for Payer: Coventry All Commercial |
$19.66
|
| Rate for Payer: Encore All Commercial |
$20.57
|
| Rate for Payer: Frontpath All Commercial |
$20.56
|
| Rate for Payer: Humana ChoiceCare |
$19.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.11
|
| Rate for Payer: PHCS All Commercial |
$16.76
|
| Rate for Payer: PHP All Commercial |
$16.95
|
| Rate for Payer: Sagamore Health Network All Products |
$17.25
|
| Rate for Payer: Signature Care EPO |
$18.55
|
| Rate for Payer: Signature Care PPO |
$19.66
|
| Rate for Payer: United Healthcare Commercial |
$17.61
|
|
|
HYDROXYCHLOROQUINE 200 MG ORAL TAB
|
Facility
|
OP
|
$5.95
|
|
|
Service Code
|
NDC 00904704606
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$5.53 |
| Rate for Payer: Aetna Commercial |
$5.02
|
| Rate for Payer: Aetna Medicare |
$1.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.72
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.09
|
| Rate for Payer: Cash Price |
$3.57
|
| Rate for Payer: Centivo All Commercial |
$3.24
|
| Rate for Payer: Cigna All Commercial |
$5.13
|
| Rate for Payer: CORVEL All Commercial |
$5.53
|
| Rate for Payer: Coventry All Commercial |
$5.24
|
| Rate for Payer: Encore All Commercial |
$5.48
|
| Rate for Payer: Frontpath All Commercial |
$5.47
|
| Rate for Payer: Humana ChoiceCare |
$5.14
|
| Rate for Payer: Humana Medicare |
$1.90
|
| Rate for Payer: Lucent All Commercial |
$3.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.36
|
| Rate for Payer: PHCS All Commercial |
$4.46
|
| Rate for Payer: PHP All Commercial |
$4.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.32
|
| Rate for Payer: Sagamore Health Network All Products |
$4.59
|
| Rate for Payer: Signature Care EPO |
$4.94
|
| Rate for Payer: Signature Care PPO |
$5.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.06
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$1.90
|
|
|
HYDROXYCHLOROQUINE 200 MG ORAL TAB
|
Facility
|
IP
|
$5.95
|
|
|
Service Code
|
NDC 00904704606
|
| Hospital Charge Code |
10235
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$5.53 |
| Rate for Payer: Aetna Commercial |
$5.14
|
| Rate for Payer: Cash Price |
$3.57
|
| Rate for Payer: Cigna All Commercial |
$5.13
|
| Rate for Payer: CORVEL All Commercial |
$5.53
|
| Rate for Payer: Coventry All Commercial |
$5.24
|
| Rate for Payer: Encore All Commercial |
$5.48
|
| Rate for Payer: Frontpath All Commercial |
$5.47
|
| Rate for Payer: Humana ChoiceCare |
$5.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.36
|
| Rate for Payer: PHCS All Commercial |
$4.46
|
| Rate for Payer: PHP All Commercial |
$4.51
|
| Rate for Payer: Sagamore Health Network All Products |
$4.59
|
| Rate for Payer: Signature Care EPO |
$4.94
|
| Rate for Payer: Signature Care PPO |
$5.24
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
|
|
HYDROXYPROGEST(PF)(PREG PRESV) 275 MG/1.1 ML SUBQ ATIN
|
Facility
|
OP
|
$3,270.40
|
|
|
Service Code
|
HCPCS J1726
|
| Hospital Charge Code |
184036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,013.82 |
| Max. Negotiated Rate |
$3,041.47 |
| Rate for Payer: Aetna Commercial |
$2,760.22
|
| Rate for Payer: Aetna Medicare |
$1,046.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,013.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,878.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,044.33
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,203.51
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,151.18
|
| Rate for Payer: Cash Price |
$1,962.24
|
| Rate for Payer: Centivo All Commercial |
$1,779.10
|
| Rate for Payer: Cigna All Commercial |
$2,822.36
|
| Rate for Payer: CORVEL All Commercial |
$3,041.47
|
| Rate for Payer: Coventry All Commercial |
$2,877.95
|
| Rate for Payer: Encore All Commercial |
$3,010.40
|
| Rate for Payer: Frontpath All Commercial |
$3,008.77
|
| Rate for Payer: Humana ChoiceCare |
$2,824.64
|
| Rate for Payer: Humana Medicare |
$1,046.53
|
| Rate for Payer: Lucent All Commercial |
$1,779.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,943.36
|
| Rate for Payer: PHCS All Commercial |
$2,452.80
|
| Rate for Payer: PHP All Commercial |
$2,480.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,275.46
|
| Rate for Payer: Sagamore Health Network All Products |
$2,524.75
|
| Rate for Payer: Signature Care EPO |
$2,714.43
|
| Rate for Payer: Signature Care PPO |
$2,877.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,779.84
|
| Rate for Payer: United Healthcare Commercial |
$2,577.08
|
| Rate for Payer: United Healthcare Medicare |
$1,046.53
|
|
|
HYDROXYPROGEST(PF)(PREG PRESV) 275 MG/1.1 ML SUBQ ATIN
|
Facility
|
IP
|
$3,270.40
|
|
|
Service Code
|
HCPCS J1726
|
| Hospital Charge Code |
184036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,452.80 |
| Max. Negotiated Rate |
$3,041.47 |
| Rate for Payer: Aetna Commercial |
$2,825.63
|
| Rate for Payer: Cash Price |
$1,962.24
|
| Rate for Payer: Cigna All Commercial |
$2,822.36
|
| Rate for Payer: CORVEL All Commercial |
$3,041.47
|
| Rate for Payer: Coventry All Commercial |
$2,877.95
|
| Rate for Payer: Encore All Commercial |
$3,010.40
|
| Rate for Payer: Frontpath All Commercial |
$3,008.77
|
| Rate for Payer: Humana ChoiceCare |
$2,824.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,943.36
|
| Rate for Payer: PHCS All Commercial |
$2,452.80
|
| Rate for Payer: PHP All Commercial |
$2,480.27
|
| Rate for Payer: Sagamore Health Network All Products |
$2,524.75
|
| Rate for Payer: Signature Care EPO |
$2,714.43
|
| Rate for Payer: Signature Care PPO |
$2,877.95
|
| Rate for Payer: United Healthcare Commercial |
$2,577.08
|
|
|
HYDROXYZINE HCL 10 MG ORAL TAB
|
Facility
|
OP
|
$1.37
|
|
|
Service Code
|
NDC 60687066401
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: Aetna Medicare |
$0.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.48
|
| Rate for Payer: Cash Price |
$0.82
|
| Rate for Payer: Centivo All Commercial |
$0.75
|
| Rate for Payer: Cigna All Commercial |
$1.18
|
| Rate for Payer: CORVEL All Commercial |
$1.28
|
| Rate for Payer: Coventry All Commercial |
$1.21
|
| Rate for Payer: Encore All Commercial |
$1.26
|
| Rate for Payer: Frontpath All Commercial |
$1.26
|
| Rate for Payer: Humana ChoiceCare |
$1.18
|
| Rate for Payer: Humana Medicare |
$0.44
|
| Rate for Payer: Lucent All Commercial |
$0.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.23
|
| Rate for Payer: PHCS All Commercial |
$1.03
|
| Rate for Payer: PHP All Commercial |
$1.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.54
|
| Rate for Payer: Sagamore Health Network All Products |
$1.06
|
| Rate for Payer: Signature Care EPO |
$1.14
|
| Rate for Payer: Signature Care PPO |
$1.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.17
|
| Rate for Payer: United Healthcare Commercial |
$1.08
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
|
|
HYDROXYZINE HCL 10 MG ORAL TAB
|
Facility
|
IP
|
$1.37
|
|
|
Service Code
|
NDC 60687066401
|
| Hospital Charge Code |
3772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna Commercial |
$1.19
|
| Rate for Payer: Cash Price |
$0.82
|
| Rate for Payer: Cigna All Commercial |
$1.18
|
| Rate for Payer: CORVEL All Commercial |
$1.28
|
| Rate for Payer: Coventry All Commercial |
$1.21
|
| Rate for Payer: Encore All Commercial |
$1.26
|
| Rate for Payer: Frontpath All Commercial |
$1.26
|
| Rate for Payer: Humana ChoiceCare |
$1.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.23
|
| Rate for Payer: PHCS All Commercial |
$1.03
|
| Rate for Payer: PHP All Commercial |
$1.04
|
| Rate for Payer: Sagamore Health Network All Products |
$1.06
|
| Rate for Payer: Signature Care EPO |
$1.14
|
| Rate for Payer: Signature Care PPO |
$1.21
|
| Rate for Payer: United Healthcare Commercial |
$1.08
|
|
|
HYDROXYZINE HCL 25 MG ORAL TAB
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 60687067511
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Cigna All Commercial |
$1.35
|
| Rate for Payer: CORVEL All Commercial |
$1.45
|
| Rate for Payer: Coventry All Commercial |
$1.37
|
| Rate for Payer: Encore All Commercial |
$1.44
|
| Rate for Payer: Frontpath All Commercial |
$1.44
|
| Rate for Payer: Humana ChoiceCare |
$1.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.40
|
| Rate for Payer: PHCS All Commercial |
$1.17
|
| Rate for Payer: PHP All Commercial |
$1.18
|
| Rate for Payer: Sagamore Health Network All Products |
$1.21
|
| Rate for Payer: Signature Care EPO |
$1.30
|
| Rate for Payer: Signature Care PPO |
$1.37
|
| Rate for Payer: United Healthcare Commercial |
$1.23
|
|
|
HYDROXYZINE HCL 25 MG ORAL TAB
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 60687067501
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna Commercial |
$1.32
|
| Rate for Payer: Aetna Medicare |
$0.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Centivo All Commercial |
$0.85
|
| Rate for Payer: Cigna All Commercial |
$1.35
|
| Rate for Payer: CORVEL All Commercial |
$1.45
|
| Rate for Payer: Coventry All Commercial |
$1.37
|
| Rate for Payer: Encore All Commercial |
$1.44
|
| Rate for Payer: Frontpath All Commercial |
$1.44
|
| Rate for Payer: Humana ChoiceCare |
$1.35
|
| Rate for Payer: Humana Medicare |
$0.50
|
| Rate for Payer: Lucent All Commercial |
$0.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.40
|
| Rate for Payer: PHCS All Commercial |
$1.17
|
| Rate for Payer: PHP All Commercial |
$1.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.61
|
| Rate for Payer: Sagamore Health Network All Products |
$1.21
|
| Rate for Payer: Signature Care EPO |
$1.30
|
| Rate for Payer: Signature Care PPO |
$1.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.33
|
| Rate for Payer: United Healthcare Commercial |
$1.23
|
| Rate for Payer: United Healthcare Medicare |
$0.50
|
|
|
HYDROXYZINE HCL 25 MG ORAL TAB
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 60687067501
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Cigna All Commercial |
$1.35
|
| Rate for Payer: CORVEL All Commercial |
$1.45
|
| Rate for Payer: Coventry All Commercial |
$1.37
|
| Rate for Payer: Encore All Commercial |
$1.44
|
| Rate for Payer: Frontpath All Commercial |
$1.44
|
| Rate for Payer: Humana ChoiceCare |
$1.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.40
|
| Rate for Payer: PHCS All Commercial |
$1.17
|
| Rate for Payer: PHP All Commercial |
$1.18
|
| Rate for Payer: Sagamore Health Network All Products |
$1.21
|
| Rate for Payer: Signature Care EPO |
$1.30
|
| Rate for Payer: Signature Care PPO |
$1.37
|
| Rate for Payer: United Healthcare Commercial |
$1.23
|
|
|
HYDROXYZINE HCL 25 MG ORAL TAB
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 60687067511
|
| Hospital Charge Code |
3774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna Commercial |
$1.32
|
| Rate for Payer: Aetna Medicare |
$0.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.55
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Centivo All Commercial |
$0.85
|
| Rate for Payer: Cigna All Commercial |
$1.35
|
| Rate for Payer: CORVEL All Commercial |
$1.45
|
| Rate for Payer: Coventry All Commercial |
$1.37
|
| Rate for Payer: Encore All Commercial |
$1.44
|
| Rate for Payer: Frontpath All Commercial |
$1.44
|
| Rate for Payer: Humana ChoiceCare |
$1.35
|
| Rate for Payer: Humana Medicare |
$0.50
|
| Rate for Payer: Lucent All Commercial |
$0.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.40
|
| Rate for Payer: PHCS All Commercial |
$1.17
|
| Rate for Payer: PHP All Commercial |
$1.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.61
|
| Rate for Payer: Sagamore Health Network All Products |
$1.21
|
| Rate for Payer: Signature Care EPO |
$1.30
|
| Rate for Payer: Signature Care PPO |
$1.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.33
|
| Rate for Payer: United Healthcare Commercial |
$1.23
|
| Rate for Payer: United Healthcare Medicare |
$0.50
|
|
|
HYDROXYZINE HCL 50 MG/ML IM SOLN
|
Facility
|
IP
|
$143.40
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
3770
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.55 |
| Max. Negotiated Rate |
$133.36 |
| Rate for Payer: Aetna Commercial |
$123.89
|
| Rate for Payer: Cash Price |
$86.04
|
| Rate for Payer: Cigna All Commercial |
$123.75
|
| Rate for Payer: CORVEL All Commercial |
$133.36
|
| Rate for Payer: Coventry All Commercial |
$126.19
|
| Rate for Payer: Encore All Commercial |
$132.00
|
| Rate for Payer: Frontpath All Commercial |
$131.92
|
| Rate for Payer: Humana ChoiceCare |
$123.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.06
|
| Rate for Payer: PHCS All Commercial |
$107.55
|
| Rate for Payer: PHP All Commercial |
$108.75
|
| Rate for Payer: Sagamore Health Network All Products |
$110.70
|
| Rate for Payer: Signature Care EPO |
$119.02
|
| Rate for Payer: Signature Care PPO |
$126.19
|
| Rate for Payer: United Healthcare Commercial |
$113.00
|
|
|
HYDROXYZINE HCL 50 MG/ML IM SOLN
|
Facility
|
OP
|
$143.40
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
3770
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.45 |
| Max. Negotiated Rate |
$133.36 |
| Rate for Payer: Aetna Commercial |
$121.03
|
| Rate for Payer: Aetna Medicare |
$45.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$44.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$82.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$89.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$52.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$50.48
|
| Rate for Payer: Cash Price |
$86.04
|
| Rate for Payer: Centivo All Commercial |
$78.01
|
| Rate for Payer: Cigna All Commercial |
$123.75
|
| Rate for Payer: CORVEL All Commercial |
$133.36
|
| Rate for Payer: Coventry All Commercial |
$126.19
|
| Rate for Payer: Encore All Commercial |
$132.00
|
| Rate for Payer: Frontpath All Commercial |
$131.92
|
| Rate for Payer: Humana ChoiceCare |
$123.85
|
| Rate for Payer: Humana Medicare |
$45.89
|
| Rate for Payer: Lucent All Commercial |
$78.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$129.06
|
| Rate for Payer: PHCS All Commercial |
$107.55
|
| Rate for Payer: PHP All Commercial |
$108.75
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$55.92
|
| Rate for Payer: Sagamore Health Network All Products |
$110.70
|
| Rate for Payer: Signature Care EPO |
$119.02
|
| Rate for Payer: Signature Care PPO |
$126.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$121.89
|
| Rate for Payer: United Healthcare Commercial |
$113.00
|
| Rate for Payer: United Healthcare Medicare |
$45.89
|
|
|
HYLAN G-F 20 48 MG/6 ML IATC SYRG
|
Facility
|
IP
|
$4,494.06
|
|
|
Service Code
|
HCPCS j7325
|
| Hospital Charge Code |
120298
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,370.55 |
| Max. Negotiated Rate |
$4,179.48 |
| Rate for Payer: Aetna Commercial |
$3,882.87
|
| Rate for Payer: Cash Price |
$2,696.44
|
| Rate for Payer: Cigna All Commercial |
$3,878.38
|
| Rate for Payer: CORVEL All Commercial |
$4,179.48
|
| Rate for Payer: Coventry All Commercial |
$3,954.78
|
| Rate for Payer: Encore All Commercial |
$4,136.78
|
| Rate for Payer: Frontpath All Commercial |
$4,134.54
|
| Rate for Payer: Humana ChoiceCare |
$3,881.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,044.66
|
| Rate for Payer: PHCS All Commercial |
$3,370.55
|
| Rate for Payer: PHP All Commercial |
$3,408.30
|
| Rate for Payer: Sagamore Health Network All Products |
$3,469.42
|
| Rate for Payer: Signature Care EPO |
$3,730.07
|
| Rate for Payer: Signature Care PPO |
$3,954.78
|
| Rate for Payer: United Healthcare Commercial |
$3,541.32
|
|
