|
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 |
$0.74
|
| 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
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 |
$0.62
|
| 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
|
|
|
HYDROCHLOROTHIAZIDE 25 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 29300012801
|
| Hospital Charge Code |
3720
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| 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 |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| 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 |
$0.33
|
|
|
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 |
$2.48
|
| 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 |
$1.32 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.04
|
| 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 |
$2.04
|
| Rate for Payer: Lucent All Commercial |
$2.04
|
| 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 |
$1.32
|
|
|
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 |
$1.32 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.04
|
| 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 |
$2.04
|
| Rate for Payer: Lucent All Commercial |
$2.04
|
| 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 |
$1.32
|
|
|
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 |
$1.32 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.45
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Centivo All Commercial |
$2.04
|
| 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 |
$2.04
|
| Rate for Payer: Lucent All Commercial |
$2.04
|
| 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 |
$1.32
|
|
|
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 |
$2.48
|
| 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 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 |
$2.48
|
| 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 TABLET #4 ED PACK (CAMERON)
|
Facility
OP
|
$13.75
|
|
|
Service Code
|
NDC 68084895
|
| Hospital Charge Code |
1401000800188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.54 |
| Max. Negotiated Rate |
$12.79 |
| Rate for Payer: Aetna Commercial |
$11.60
|
| Rate for Payer: Aetna Medicare |
$4.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.99
|
| Rate for Payer: Cash Price |
$8.52
|
| Rate for Payer: Centivo All Commercial |
$7.01
|
| Rate for Payer: Cigna All Commercial |
$11.86
|
| Rate for Payer: CORVEL All Commercial |
$12.79
|
| Rate for Payer: Coventry All Commercial |
$12.10
|
| Rate for Payer: Encore All Commercial |
$12.66
|
| Rate for Payer: Frontpath All Commercial |
$12.65
|
| Rate for Payer: Humana ChoiceCare |
$11.87
|
| Rate for Payer: Humana Medicare |
$7.01
|
| Rate for Payer: Lucent All Commercial |
$7.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.37
|
| Rate for Payer: PHCS All Commercial |
$10.31
|
| Rate for Payer: PHP All Commercial |
$10.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.36
|
| Rate for Payer: Sagamore Health Network All Products |
$10.61
|
| Rate for Payer: Signature Care EPO |
$11.41
|
| Rate for Payer: Signature Care PPO |
$12.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.69
|
| Rate for Payer: United Healthcare Commercial |
$10.83
|
| Rate for Payer: United Healthcare Medicare |
$4.54
|
|
|
HYDROCODONE-ACETAMINOPHEN 5-325 MG TABLET #4 ED PACK (CAMERON)
|
Facility
IP
|
$13.75
|
|
|
Service Code
|
NDC 68084895
|
| Hospital Charge Code |
1401000800188
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$10.31 |
| Max. Negotiated Rate |
$12.79 |
| Rate for Payer: Aetna Commercial |
$11.88
|
| Rate for Payer: Cash Price |
$8.52
|
| Rate for Payer: Cigna All Commercial |
$11.86
|
| Rate for Payer: CORVEL All Commercial |
$12.79
|
| Rate for Payer: Coventry All Commercial |
$12.10
|
| Rate for Payer: Encore All Commercial |
$12.66
|
| Rate for Payer: Frontpath All Commercial |
$12.65
|
| Rate for Payer: Humana ChoiceCare |
$11.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.37
|
| Rate for Payer: PHCS All Commercial |
$10.31
|
| Rate for Payer: PHP All Commercial |
$10.43
|
| Rate for Payer: Sagamore Health Network All Products |
$10.61
|
| Rate for Payer: Signature Care EPO |
$11.41
|
| Rate for Payer: Signature Care PPO |
$12.10
|
| Rate for Payer: United Healthcare Commercial |
$10.83
|
|
|
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML ORAL SOLN
|
Facility
OP
|
$28.46
|
|
|
Service Code
|
NDC 00121231615
|
| Hospital Charge Code |
37848
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.39 |
| Max. Negotiated Rate |
$26.46 |
| Rate for Payer: Aetna Commercial |
$24.02
|
| Rate for Payer: Aetna Medicare |
$9.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.33
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Centivo All Commercial |
$14.51
|
| Rate for Payer: Cigna All Commercial |
$24.56
|
| Rate for Payer: CORVEL All Commercial |
$26.46
|
| Rate for Payer: Coventry All Commercial |
$25.04
|
| Rate for Payer: Encore All Commercial |
$26.19
|
| Rate for Payer: Frontpath All Commercial |
$26.18
|
| Rate for Payer: Humana ChoiceCare |
$24.58
|
| Rate for Payer: Humana Medicare |
$14.51
|
| Rate for Payer: Lucent All Commercial |
$14.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.61
|
| Rate for Payer: PHCS All Commercial |
$21.34
|
| Rate for Payer: PHP All Commercial |
$21.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.10
|
| Rate for Payer: Sagamore Health Network All Products |
$21.97
|
| Rate for Payer: Signature Care EPO |
$23.62
|
| Rate for Payer: Signature Care PPO |
$25.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.19
|
| Rate for Payer: United Healthcare Commercial |
$22.42
|
| Rate for Payer: United Healthcare Medicare |
$9.39
|
|
|
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML ORAL SOLN
|
Facility
IP
|
$28.46
|
|
|
Service Code
|
NDC 00121231615
|
| Hospital Charge Code |
37848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.34 |
| Max. Negotiated Rate |
$26.46 |
| Rate for Payer: Aetna Commercial |
$24.59
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cigna All Commercial |
$24.56
|
| Rate for Payer: CORVEL All Commercial |
$26.46
|
| Rate for Payer: Coventry All Commercial |
$25.04
|
| Rate for Payer: Encore All Commercial |
$26.19
|
| Rate for Payer: Frontpath All Commercial |
$26.18
|
| Rate for Payer: Humana ChoiceCare |
$24.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.61
|
| Rate for Payer: PHCS All Commercial |
$21.34
|
| Rate for Payer: PHP All Commercial |
$21.58
|
| Rate for Payer: Sagamore Health Network All Products |
$21.97
|
| Rate for Payer: Signature Care EPO |
$23.62
|
| Rate for Payer: Signature Care PPO |
$25.04
|
| Rate for Payer: United Healthcare Commercial |
$22.42
|
|
|
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML ORAL SOLN
|
Facility
IP
|
$28.46
|
|
|
Service Code
|
NDC 00121231650
|
| Hospital Charge Code |
37848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.34 |
| Max. Negotiated Rate |
$26.46 |
| Rate for Payer: Aetna Commercial |
$24.59
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cigna All Commercial |
$24.56
|
| Rate for Payer: CORVEL All Commercial |
$26.46
|
| Rate for Payer: Coventry All Commercial |
$25.04
|
| Rate for Payer: Encore All Commercial |
$26.19
|
| Rate for Payer: Frontpath All Commercial |
$26.18
|
| Rate for Payer: Humana ChoiceCare |
$24.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.61
|
| Rate for Payer: PHCS All Commercial |
$21.34
|
| Rate for Payer: PHP All Commercial |
$21.58
|
| Rate for Payer: Sagamore Health Network All Products |
$21.97
|
| Rate for Payer: Signature Care EPO |
$23.62
|
| Rate for Payer: Signature Care PPO |
$25.04
|
| Rate for Payer: United Healthcare Commercial |
$22.42
|
|
|
HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML ORAL SOLN
|
Facility
OP
|
$28.46
|
|
|
Service Code
|
NDC 00121231650
|
| Hospital Charge Code |
37848
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.39 |
| Max. Negotiated Rate |
$26.46 |
| Rate for Payer: Aetna Commercial |
$24.02
|
| Rate for Payer: Aetna Medicare |
$9.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.33
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Centivo All Commercial |
$14.51
|
| Rate for Payer: Cigna All Commercial |
$24.56
|
| Rate for Payer: CORVEL All Commercial |
$26.46
|
| Rate for Payer: Coventry All Commercial |
$25.04
|
| Rate for Payer: Encore All Commercial |
$26.19
|
| Rate for Payer: Frontpath All Commercial |
$26.18
|
| Rate for Payer: Humana ChoiceCare |
$24.58
|
| Rate for Payer: Humana Medicare |
$14.51
|
| Rate for Payer: Lucent All Commercial |
$14.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.61
|
| Rate for Payer: PHCS All Commercial |
$21.34
|
| Rate for Payer: PHP All Commercial |
$21.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.10
|
| Rate for Payer: Sagamore Health Network All Products |
$21.97
|
| Rate for Payer: Signature Care EPO |
$23.62
|
| Rate for Payer: Signature Care PPO |
$25.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.19
|
| Rate for Payer: United Healthcare Commercial |
$22.42
|
| Rate for Payer: United Healthcare Medicare |
$9.39
|
|
|
HYDROCODONE-CHLORPHENIRAMINE 10-8 MG/5 ML ORAL SU12
|
Facility
OP
|
$14.04
|
|
|
Service Code
|
NDC 278080086
|
| Hospital Charge Code |
106413
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.63 |
| Max. Negotiated Rate |
$13.05 |
| Rate for Payer: Aetna Commercial |
$11.85
|
| Rate for Payer: Aetna Medicare |
$4.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.09
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Centivo All Commercial |
$7.16
|
| Rate for Payer: Cigna All Commercial |
$12.11
|
| Rate for Payer: CORVEL All Commercial |
$13.05
|
| Rate for Payer: Coventry All Commercial |
$12.35
|
| Rate for Payer: Encore All Commercial |
$12.92
|
| Rate for Payer: Frontpath All Commercial |
$12.91
|
| Rate for Payer: Humana ChoiceCare |
$12.12
|
| Rate for Payer: Humana Medicare |
$7.16
|
| Rate for Payer: Lucent All Commercial |
$7.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.63
|
| Rate for Payer: PHCS All Commercial |
$10.53
|
| Rate for Payer: PHP All Commercial |
$10.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.47
|
| Rate for Payer: Sagamore Health Network All Products |
$10.84
|
| Rate for Payer: Signature Care EPO |
$11.65
|
| Rate for Payer: Signature Care PPO |
$12.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$11.93
|
| Rate for Payer: United Healthcare Commercial |
$11.06
|
| Rate for Payer: United Healthcare Medicare |
$4.63
|
|
|
HYDROCODONE-CHLORPHENIRAMINE 10-8 MG/5 ML ORAL SU12
|
Facility
IP
|
$385.02
|
|
|
Service Code
|
NDC 27808008601
|
| Hospital Charge Code |
106413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$288.76 |
| Max. Negotiated Rate |
$358.07 |
| Rate for Payer: Aetna Commercial |
$332.66
|
| Rate for Payer: Cash Price |
$238.71
|
| Rate for Payer: Cigna All Commercial |
$332.27
|
| Rate for Payer: CORVEL All Commercial |
$358.07
|
| Rate for Payer: Coventry All Commercial |
$338.82
|
| Rate for Payer: Encore All Commercial |
$354.41
|
| Rate for Payer: Frontpath All Commercial |
$354.22
|
| Rate for Payer: Humana ChoiceCare |
$332.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$346.52
|
| Rate for Payer: PHCS All Commercial |
$288.76
|
| Rate for Payer: PHP All Commercial |
$292.00
|
| Rate for Payer: Sagamore Health Network All Products |
$297.24
|
| Rate for Payer: Signature Care EPO |
$319.57
|
| Rate for Payer: Signature Care PPO |
$338.82
|
| Rate for Payer: United Healthcare Commercial |
$303.40
|
|
|
HYDROCODONE-CHLORPHENIRAMINE 10-8 MG/5 ML ORAL SU12
|
Facility
IP
|
$14.04
|
|
|
Service Code
|
NDC 278080086
|
| Hospital Charge Code |
106413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$13.05 |
| Rate for Payer: Aetna Commercial |
$12.13
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna All Commercial |
$12.11
|
| Rate for Payer: CORVEL All Commercial |
$13.05
|
| Rate for Payer: Coventry All Commercial |
$12.35
|
| Rate for Payer: Encore All Commercial |
$12.92
|
| Rate for Payer: Frontpath All Commercial |
$12.91
|
| Rate for Payer: Humana ChoiceCare |
$12.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.63
|
| Rate for Payer: PHCS All Commercial |
$10.53
|
| Rate for Payer: PHP All Commercial |
$10.64
|
| Rate for Payer: Sagamore Health Network All Products |
$10.84
|
| Rate for Payer: Signature Care EPO |
$11.65
|
| Rate for Payer: Signature Care PPO |
$12.35
|
| Rate for Payer: United Healthcare Commercial |
$11.06
|
|
|
HYDROCODONE-CHLORPHENIRAMINE 10-8 MG/5 ML ORAL SU12
|
Facility
OP
|
$385.02
|
|
|
Service Code
|
NDC 27808008601
|
| Hospital Charge Code |
106413
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.06 |
| Max. Negotiated Rate |
$358.07 |
| Rate for Payer: Aetna Commercial |
$324.96
|
| Rate for Payer: Aetna Medicare |
$127.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$127.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$221.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$240.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$146.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$139.76
|
| Rate for Payer: Cash Price |
$238.71
|
| Rate for Payer: Centivo All Commercial |
$196.36
|
| Rate for Payer: Cigna All Commercial |
$332.27
|
| Rate for Payer: CORVEL All Commercial |
$358.07
|
| Rate for Payer: Coventry All Commercial |
$338.82
|
| Rate for Payer: Encore All Commercial |
$354.41
|
| Rate for Payer: Frontpath All Commercial |
$354.22
|
| Rate for Payer: Humana ChoiceCare |
$332.54
|
| Rate for Payer: Humana Medicare |
$196.36
|
| Rate for Payer: Lucent All Commercial |
$196.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$346.52
|
| Rate for Payer: PHCS All Commercial |
$288.76
|
| Rate for Payer: PHP All Commercial |
$292.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$150.16
|
| Rate for Payer: Sagamore Health Network All Products |
$297.24
|
| Rate for Payer: Signature Care EPO |
$319.57
|
| Rate for Payer: Signature Care PPO |
$338.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$327.27
|
| Rate for Payer: United Healthcare Commercial |
$303.40
|
| Rate for Payer: United Healthcare Medicare |
$127.06
|
|
|
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 |
$2.23
|
| 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 20 MG ORAL TAB
|
Facility
OP
|
$3.60
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
3734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Aetna Commercial |
$3.04
|
| Rate for Payer: Aetna Medicare |
$1.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.31
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Centivo All Commercial |
$1.83
|
| 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 |
$1.83
|
| Rate for Payer: Lucent All Commercial |
$1.83
|
| 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 |
$1.19
|
|
|
HYDROCORTISONE 2.5 % TOP CREA
|
Facility
OP
|
$14.91
|
|
|
Service Code
|
NDC 00168008031
|
| Hospital Charge Code |
3727
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$13.87 |
| Rate for Payer: Aetna Commercial |
$12.58
|
| Rate for Payer: Aetna Medicare |
$4.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$9.32
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.41
|
| Rate for Payer: Cash Price |
$9.24
|
| Rate for Payer: Centivo All Commercial |
$7.60
|
| Rate for Payer: Cigna All Commercial |
$12.87
|
| Rate for Payer: CORVEL All Commercial |
$13.87
|
| Rate for Payer: Coventry All Commercial |
$13.12
|
| Rate for Payer: Encore All Commercial |
$13.72
|
| Rate for Payer: Frontpath All Commercial |
$13.72
|
| Rate for Payer: Humana ChoiceCare |
$12.88
|
| Rate for Payer: Humana Medicare |
$7.60
|
| Rate for Payer: Lucent All Commercial |
$7.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.42
|
| Rate for Payer: PHCS All Commercial |
$11.18
|
| Rate for Payer: PHP All Commercial |
$11.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.81
|
| Rate for Payer: Sagamore Health Network All Products |
$11.51
|
| Rate for Payer: Signature Care EPO |
$12.38
|
| Rate for Payer: Signature Care PPO |
$13.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.67
|
| Rate for Payer: United Healthcare Commercial |
$11.75
|
| Rate for Payer: United Healthcare Medicare |
$4.92
|
|
|
HYDROCORTISONE 2.5 % TOP CREA
|
Facility
IP
|
$14.91
|
|
|
Service Code
|
NDC 00168008031
|
| Hospital Charge Code |
3727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.18 |
| Max. Negotiated Rate |
$13.87 |
| Rate for Payer: Aetna Commercial |
$12.88
|
| Rate for Payer: Cash Price |
$9.24
|
| Rate for Payer: Cigna All Commercial |
$12.87
|
| Rate for Payer: CORVEL All Commercial |
$13.87
|
| Rate for Payer: Coventry All Commercial |
$13.12
|
| Rate for Payer: Encore All Commercial |
$13.72
|
| Rate for Payer: Frontpath All Commercial |
$13.72
|
| Rate for Payer: Humana ChoiceCare |
$12.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$13.42
|
| Rate for Payer: PHCS All Commercial |
$11.18
|
| Rate for Payer: PHP All Commercial |
$11.31
|
| Rate for Payer: Sagamore Health Network All Products |
$11.51
|
| Rate for Payer: Signature Care EPO |
$12.38
|
| Rate for Payer: Signature Care PPO |
$13.12
|
| Rate for Payer: United Healthcare Commercial |
$11.75
|
|
|
HYDROCORTISONE 2.5 % TOP LOTN
|
Facility
OP
|
$40.89
|
|
|
Service Code
|
NDC 45802093716
|
| Hospital Charge Code |
3729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.49 |
| Max. Negotiated Rate |
$38.02 |
| Rate for Payer: Aetna Commercial |
$34.51
|
| Rate for Payer: Aetna Medicare |
$13.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$13.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$23.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$25.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$15.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$14.84
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Centivo All Commercial |
$20.85
|
| Rate for Payer: Cigna All Commercial |
$35.29
|
| Rate for Payer: CORVEL All Commercial |
$38.02
|
| Rate for Payer: Coventry All Commercial |
$35.98
|
| Rate for Payer: Encore All Commercial |
$37.64
|
| Rate for Payer: Frontpath All Commercial |
$37.62
|
| Rate for Payer: Humana ChoiceCare |
$35.31
|
| Rate for Payer: Humana Medicare |
$20.85
|
| Rate for Payer: Lucent All Commercial |
$20.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$36.80
|
| Rate for Payer: PHCS All Commercial |
$30.67
|
| Rate for Payer: PHP All Commercial |
$31.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.95
|
| Rate for Payer: Sagamore Health Network All Products |
$31.56
|
| Rate for Payer: Signature Care EPO |
$33.94
|
| Rate for Payer: Signature Care PPO |
$35.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$34.75
|
| Rate for Payer: United Healthcare Commercial |
$32.22
|
| Rate for Payer: United Healthcare Medicare |
$13.49
|
|
|
HYDROCORTISONE 2.5 % TOP LOTN
|
Facility
IP
|
$40.89
|
|
|
Service Code
|
NDC 45802093716
|
| Hospital Charge Code |
3729
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.67 |
| Max. Negotiated Rate |
$38.02 |
| Rate for Payer: Aetna Commercial |
$35.33
|
| Rate for Payer: Cash Price |
$25.35
|
| Rate for Payer: Cigna All Commercial |
$35.29
|
| Rate for Payer: CORVEL All Commercial |
$38.02
|
| Rate for Payer: Coventry All Commercial |
$35.98
|
| Rate for Payer: Encore All Commercial |
$37.64
|
| Rate for Payer: Frontpath All Commercial |
$37.62
|
| Rate for Payer: Humana ChoiceCare |
$35.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$36.80
|
| Rate for Payer: PHCS All Commercial |
$30.67
|
| Rate for Payer: PHP All Commercial |
$31.01
|
| Rate for Payer: Sagamore Health Network All Products |
$31.56
|
| Rate for Payer: Signature Care EPO |
$33.94
|
| Rate for Payer: Signature Care PPO |
$35.98
|
| Rate for Payer: United Healthcare Commercial |
$32.22
|
|
