|
HYDROCORTISONE 2.5 % TOP OINT
|
Facility
IP
|
$23.62
|
|
|
Service Code
|
NDC 00168014630
|
| Hospital Charge Code |
3732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.71 |
| Max. Negotiated Rate |
$21.96 |
| Rate for Payer: Aetna Commercial |
$20.40
|
| Rate for Payer: Cash Price |
$14.64
|
| Rate for Payer: Cigna All Commercial |
$20.38
|
| Rate for Payer: CORVEL All Commercial |
$21.96
|
| Rate for Payer: Coventry All Commercial |
$20.78
|
| Rate for Payer: Encore All Commercial |
$21.74
|
| Rate for Payer: Frontpath All Commercial |
$21.73
|
| Rate for Payer: Humana ChoiceCare |
$20.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.25
|
| Rate for Payer: PHCS All Commercial |
$17.71
|
| Rate for Payer: PHP All Commercial |
$17.91
|
| Rate for Payer: Sagamore Health Network All Products |
$18.23
|
| Rate for Payer: Signature Care EPO |
$19.60
|
| Rate for Payer: Signature Care PPO |
$20.78
|
| Rate for Payer: United Healthcare Commercial |
$18.61
|
|
|
HYDROCORTISONE 2.5 % TOP OINT
|
Facility
OP
|
$23.62
|
|
|
Service Code
|
NDC 00168014630
|
| Hospital Charge Code |
3732
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.79 |
| Max. Negotiated Rate |
$21.96 |
| Rate for Payer: Aetna Commercial |
$19.93
|
| Rate for Payer: Aetna Medicare |
$7.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.79
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$13.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$14.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.57
|
| Rate for Payer: Cash Price |
$14.64
|
| Rate for Payer: Centivo All Commercial |
$12.04
|
| Rate for Payer: Cigna All Commercial |
$20.38
|
| Rate for Payer: CORVEL All Commercial |
$21.96
|
| Rate for Payer: Coventry All Commercial |
$20.78
|
| Rate for Payer: Encore All Commercial |
$21.74
|
| Rate for Payer: Frontpath All Commercial |
$21.73
|
| Rate for Payer: Humana ChoiceCare |
$20.40
|
| Rate for Payer: Humana Medicare |
$12.04
|
| Rate for Payer: Lucent All Commercial |
$12.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$21.25
|
| Rate for Payer: PHCS All Commercial |
$17.71
|
| Rate for Payer: PHP All Commercial |
$17.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.21
|
| Rate for Payer: Sagamore Health Network All Products |
$18.23
|
| Rate for Payer: Signature Care EPO |
$19.60
|
| Rate for Payer: Signature Care PPO |
$20.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$20.07
|
| Rate for Payer: United Healthcare Commercial |
$18.61
|
| Rate for Payer: United Healthcare Medicare |
$7.79
|
|
|
HYDROCORTISONE ACETATE 25 MG RECT SUPP
|
Facility
OP
|
$11.29
|
|
|
Service Code
|
NDC 16571067621
|
| Hospital Charge Code |
3738
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$10.50 |
| Rate for Payer: Aetna Commercial |
$9.53
|
| Rate for Payer: Aetna Medicare |
$3.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$7.06
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4.10
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: Centivo All Commercial |
$5.76
|
| Rate for Payer: Cigna All Commercial |
$9.74
|
| Rate for Payer: CORVEL All Commercial |
$10.50
|
| Rate for Payer: Coventry All Commercial |
$9.94
|
| Rate for Payer: Encore All Commercial |
$10.39
|
| Rate for Payer: Frontpath All Commercial |
$10.39
|
| Rate for Payer: Humana ChoiceCare |
$9.75
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$5.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.16
|
| Rate for Payer: PHCS All Commercial |
$8.47
|
| Rate for Payer: PHP All Commercial |
$8.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.40
|
| Rate for Payer: Sagamore Health Network All Products |
$8.72
|
| Rate for Payer: Signature Care EPO |
$9.37
|
| Rate for Payer: Signature Care PPO |
$9.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9.60
|
| Rate for Payer: United Healthcare Commercial |
$8.90
|
| Rate for Payer: United Healthcare Medicare |
$3.73
|
|
|
HYDROCORTISONE ACETATE 25 MG RECT SUPP
|
Facility
IP
|
$11.29
|
|
|
Service Code
|
NDC 16571067621
|
| Hospital Charge Code |
3738
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.47 |
| Max. Negotiated Rate |
$10.50 |
| Rate for Payer: Aetna Commercial |
$9.76
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: Cigna All Commercial |
$9.74
|
| Rate for Payer: CORVEL All Commercial |
$10.50
|
| Rate for Payer: Coventry All Commercial |
$9.94
|
| Rate for Payer: Encore All Commercial |
$10.39
|
| Rate for Payer: Frontpath All Commercial |
$10.39
|
| Rate for Payer: Humana ChoiceCare |
$9.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$10.16
|
| Rate for Payer: PHCS All Commercial |
$8.47
|
| Rate for Payer: PHP All Commercial |
$8.56
|
| Rate for Payer: Sagamore Health Network All Products |
$8.72
|
| Rate for Payer: Signature Care EPO |
$9.37
|
| Rate for Payer: Signature Care PPO |
$9.94
|
| Rate for Payer: United Healthcare Commercial |
$8.90
|
|
|
HYDROCORTISONE-ALOE VERA 1 % TOP CREA
|
Facility
OP
|
$10.78
|
|
|
Service Code
|
NDC 00536140795
|
| Hospital Charge Code |
14190
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$10.03 |
| Rate for Payer: Aetna Commercial |
$9.10
|
| Rate for Payer: Aetna Medicare |
$3.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.91
|
| Rate for Payer: Cash Price |
$6.68
|
| Rate for Payer: Centivo All Commercial |
$5.50
|
| Rate for Payer: Cigna All Commercial |
$9.30
|
| Rate for Payer: CORVEL All Commercial |
$10.03
|
| Rate for Payer: Coventry All Commercial |
$9.49
|
| Rate for Payer: Encore All Commercial |
$9.92
|
| Rate for Payer: Frontpath All Commercial |
$9.92
|
| Rate for Payer: Humana ChoiceCare |
$9.31
|
| Rate for Payer: Humana Medicare |
$5.50
|
| Rate for Payer: Lucent All Commercial |
$5.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.70
|
| Rate for Payer: PHCS All Commercial |
$8.08
|
| Rate for Payer: PHP All Commercial |
$8.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4.20
|
| Rate for Payer: Sagamore Health Network All Products |
$8.32
|
| Rate for Payer: Signature Care EPO |
$8.95
|
| Rate for Payer: Signature Care PPO |
$9.49
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9.16
|
| Rate for Payer: United Healthcare Commercial |
$8.49
|
| Rate for Payer: United Healthcare Medicare |
$3.56
|
|
|
HYDROCORTISONE-ALOE VERA 1 % TOP CREA
|
Facility
IP
|
$10.78
|
|
|
Service Code
|
NDC 00536140795
|
| Hospital Charge Code |
14190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$10.03 |
| Rate for Payer: Aetna Commercial |
$9.31
|
| Rate for Payer: Cash Price |
$6.68
|
| Rate for Payer: Cigna All Commercial |
$9.30
|
| Rate for Payer: CORVEL All Commercial |
$10.03
|
| Rate for Payer: Coventry All Commercial |
$9.49
|
| Rate for Payer: Encore All Commercial |
$9.92
|
| Rate for Payer: Frontpath All Commercial |
$9.92
|
| Rate for Payer: Humana ChoiceCare |
$9.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.70
|
| Rate for Payer: PHCS All Commercial |
$8.08
|
| Rate for Payer: PHP All Commercial |
$8.18
|
| Rate for Payer: Sagamore Health Network All Products |
$8.32
|
| Rate for Payer: Signature Care EPO |
$8.95
|
| Rate for Payer: Signature Care PPO |
$9.49
|
| Rate for Payer: United Healthcare Commercial |
$8.49
|
|
|
HYDROCORTISONE-PRAMOXINE 2.5-1 % RECT CREA
|
Facility
IP
|
$574.50
|
|
|
Service Code
|
NDC 45802047264
|
| Hospital Charge Code |
28848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$430.88 |
| Max. Negotiated Rate |
$534.28 |
| Rate for Payer: Aetna Commercial |
$496.37
|
| Rate for Payer: Cash Price |
$356.19
|
| Rate for Payer: Cigna All Commercial |
$495.79
|
| Rate for Payer: CORVEL All Commercial |
$534.28
|
| Rate for Payer: Coventry All Commercial |
$505.56
|
| Rate for Payer: Encore All Commercial |
$528.83
|
| Rate for Payer: Frontpath All Commercial |
$528.54
|
| Rate for Payer: Humana ChoiceCare |
$496.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$517.05
|
| Rate for Payer: PHCS All Commercial |
$430.88
|
| Rate for Payer: PHP All Commercial |
$435.70
|
| Rate for Payer: Sagamore Health Network All Products |
$443.51
|
| Rate for Payer: Signature Care EPO |
$476.84
|
| Rate for Payer: Signature Care PPO |
$505.56
|
| Rate for Payer: United Healthcare Commercial |
$452.71
|
|
|
HYDROCORTISONE-PRAMOXINE 2.5-1 % RECT CREA
|
Facility
OP
|
$574.50
|
|
|
Service Code
|
NDC 45802047264
|
| Hospital Charge Code |
28848
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$189.58 |
| Max. Negotiated Rate |
$534.28 |
| Rate for Payer: Aetna Commercial |
$484.88
|
| Rate for Payer: Aetna Medicare |
$189.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$189.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$329.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$359.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$218.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$208.54
|
| Rate for Payer: Cash Price |
$356.19
|
| Rate for Payer: Centivo All Commercial |
$293.00
|
| Rate for Payer: Cigna All Commercial |
$495.79
|
| Rate for Payer: CORVEL All Commercial |
$534.28
|
| Rate for Payer: Coventry All Commercial |
$505.56
|
| Rate for Payer: Encore All Commercial |
$528.83
|
| Rate for Payer: Frontpath All Commercial |
$528.54
|
| Rate for Payer: Humana ChoiceCare |
$496.20
|
| Rate for Payer: Humana Medicare |
$293.00
|
| Rate for Payer: Lucent All Commercial |
$293.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$517.05
|
| Rate for Payer: PHCS All Commercial |
$430.88
|
| Rate for Payer: PHP All Commercial |
$435.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$224.06
|
| Rate for Payer: Sagamore Health Network All Products |
$443.51
|
| Rate for Payer: Signature Care EPO |
$476.84
|
| Rate for Payer: Signature Care PPO |
$505.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$488.32
|
| Rate for Payer: United Healthcare Commercial |
$452.71
|
| Rate for Payer: United Healthcare Medicare |
$189.58
|
|
|
HYDROCORTISONE SOD SUCCINATE 100 MG INJ SOLR
|
Facility
IP
|
$101.01
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
111163
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.76 |
| Max. Negotiated Rate |
$93.94 |
| Rate for Payer: Aetna Commercial |
$87.27
|
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Cigna All Commercial |
$87.17
|
| Rate for Payer: CORVEL All Commercial |
$93.94
|
| Rate for Payer: Coventry All Commercial |
$88.89
|
| Rate for Payer: Encore All Commercial |
$92.98
|
| Rate for Payer: Frontpath All Commercial |
$92.93
|
| Rate for Payer: Humana ChoiceCare |
$87.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.91
|
| Rate for Payer: PHCS All Commercial |
$75.76
|
| Rate for Payer: PHP All Commercial |
$76.61
|
| Rate for Payer: Sagamore Health Network All Products |
$77.98
|
| Rate for Payer: Signature Care EPO |
$83.84
|
| Rate for Payer: Signature Care PPO |
$88.89
|
| Rate for Payer: United Healthcare Commercial |
$79.60
|
|
|
HYDROCORTISONE SOD SUCCINATE 100 MG INJ SOLR
|
Facility
OP
|
$101.01
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
111163
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.33 |
| Max. Negotiated Rate |
$93.94 |
| Rate for Payer: Aetna Commercial |
$85.25
|
| Rate for Payer: Aetna Medicare |
$33.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$58.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$63.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$38.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.67
|
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Centivo All Commercial |
$51.52
|
| Rate for Payer: Cigna All Commercial |
$87.17
|
| Rate for Payer: CORVEL All Commercial |
$93.94
|
| Rate for Payer: Coventry All Commercial |
$88.89
|
| Rate for Payer: Encore All Commercial |
$92.98
|
| Rate for Payer: Frontpath All Commercial |
$92.93
|
| Rate for Payer: Humana ChoiceCare |
$87.24
|
| Rate for Payer: Humana Medicare |
$51.52
|
| Rate for Payer: Lucent All Commercial |
$51.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.91
|
| Rate for Payer: PHCS All Commercial |
$75.76
|
| Rate for Payer: PHP All Commercial |
$76.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.39
|
| Rate for Payer: Sagamore Health Network All Products |
$77.98
|
| Rate for Payer: Signature Care EPO |
$83.84
|
| Rate for Payer: Signature Care PPO |
$88.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$85.86
|
| Rate for Payer: United Healthcare Commercial |
$79.60
|
| Rate for Payer: United Healthcare Medicare |
$33.33
|
|
|
HYDROCORTISONE SOD SUCC (PF) 250 MG/2 ML INJ SOLR
|
Facility
IP
|
$256.62
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
121170
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$192.46 |
| Max. Negotiated Rate |
$238.66 |
| Rate for Payer: Aetna Commercial |
$221.72
|
| Rate for Payer: Cash Price |
$159.10
|
| Rate for Payer: Cigna All Commercial |
$221.46
|
| Rate for Payer: CORVEL All Commercial |
$238.66
|
| Rate for Payer: Coventry All Commercial |
$225.83
|
| Rate for Payer: Encore All Commercial |
$236.22
|
| Rate for Payer: Frontpath All Commercial |
$236.09
|
| Rate for Payer: Humana ChoiceCare |
$221.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$230.96
|
| Rate for Payer: PHCS All Commercial |
$192.46
|
| Rate for Payer: PHP All Commercial |
$194.62
|
| Rate for Payer: Sagamore Health Network All Products |
$198.11
|
| Rate for Payer: Signature Care EPO |
$212.99
|
| Rate for Payer: Signature Care PPO |
$225.83
|
| Rate for Payer: United Healthcare Commercial |
$202.22
|
|
|
HYDROCORTISONE SOD SUCC (PF) 250 MG/2 ML INJ SOLR
|
Facility
OP
|
$256.62
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
121170
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.68 |
| Max. Negotiated Rate |
$238.66 |
| Rate for Payer: Aetna Commercial |
$216.59
|
| Rate for Payer: Aetna Medicare |
$84.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$84.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$147.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$160.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$97.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$93.15
|
| Rate for Payer: Cash Price |
$159.10
|
| Rate for Payer: Centivo All Commercial |
$130.88
|
| Rate for Payer: Cigna All Commercial |
$221.46
|
| Rate for Payer: CORVEL All Commercial |
$238.66
|
| Rate for Payer: Coventry All Commercial |
$225.83
|
| Rate for Payer: Encore All Commercial |
$236.22
|
| Rate for Payer: Frontpath All Commercial |
$236.09
|
| Rate for Payer: Humana ChoiceCare |
$221.64
|
| Rate for Payer: Humana Medicare |
$130.88
|
| Rate for Payer: Lucent All Commercial |
$130.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$230.96
|
| Rate for Payer: PHCS All Commercial |
$192.46
|
| Rate for Payer: PHP All Commercial |
$194.62
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$100.08
|
| Rate for Payer: Sagamore Health Network All Products |
$198.11
|
| Rate for Payer: Signature Care EPO |
$212.99
|
| Rate for Payer: Signature Care PPO |
$225.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$218.13
|
| Rate for Payer: United Healthcare Commercial |
$202.22
|
| Rate for Payer: United Healthcare Medicare |
$84.68
|
|
|
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
164910
|
|
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 |
$11.16
|
| 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 0.5 MG/0.5 ML INJ SYRG
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
164910
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| 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 |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| 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 |
$5.94
|
|
|
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG S.O. (CAMERON)
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
140180106
|
|
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 |
$11.16
|
| 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 0.5 MG/0.5 ML INJ SYRG S.O. (CAMERON)
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
140180106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| 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 |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| 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 |
$5.94
|
|
|
HYDROMORPHONE 1 MG/ML INJ S.O.
|
Facility
OP
|
$22.34
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
408114223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.37 |
| Max. Negotiated Rate |
$20.78 |
| Rate for Payer: Aetna Commercial |
$18.86
|
| Rate for Payer: Aetna Commercial |
$24.15
|
| Rate for Payer: Aetna Medicare |
$9.44
|
| Rate for Payer: Aetna Medicare |
$7.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$12.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.89
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.11
|
| Rate for Payer: Cash Price |
$13.85
|
| Rate for Payer: Cash Price |
$17.74
|
| Rate for Payer: Centivo All Commercial |
$11.40
|
| Rate for Payer: Centivo All Commercial |
$14.59
|
| Rate for Payer: Cigna All Commercial |
$24.70
|
| Rate for Payer: Cigna All Commercial |
$19.28
|
| Rate for Payer: CORVEL All Commercial |
$26.61
|
| Rate for Payer: CORVEL All Commercial |
$20.78
|
| Rate for Payer: Coventry All Commercial |
$19.66
|
| Rate for Payer: Coventry All Commercial |
$25.18
|
| Rate for Payer: Encore All Commercial |
$26.34
|
| Rate for Payer: Encore All Commercial |
$20.57
|
| Rate for Payer: Frontpath All Commercial |
$20.56
|
| Rate for Payer: Frontpath All Commercial |
$26.33
|
| Rate for Payer: Humana ChoiceCare |
$24.72
|
| Rate for Payer: Humana ChoiceCare |
$19.30
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Humana Medicare |
$14.59
|
| Rate for Payer: Lucent All Commercial |
$11.40
|
| Rate for Payer: Lucent All Commercial |
$14.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.75
|
| Rate for Payer: PHCS All Commercial |
$16.76
|
| Rate for Payer: PHCS All Commercial |
$21.46
|
| Rate for Payer: PHP All Commercial |
$21.70
|
| Rate for Payer: PHP All Commercial |
$16.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.16
|
| Rate for Payer: Sagamore Health Network All Products |
$17.25
|
| Rate for Payer: Sagamore Health Network All Products |
$22.09
|
| Rate for Payer: Signature Care EPO |
$23.75
|
| Rate for Payer: Signature Care EPO |
$18.55
|
| Rate for Payer: Signature Care PPO |
$19.66
|
| Rate for Payer: Signature Care PPO |
$25.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.99
|
| Rate for Payer: United Healthcare Commercial |
$17.61
|
| Rate for Payer: United Healthcare Commercial |
$22.55
|
| Rate for Payer: United Healthcare Medicare |
$7.37
|
| Rate for Payer: United Healthcare Medicare |
$9.44
|
|
|
HYDROMORPHONE 1 MG/ML INJ S.O.
|
Facility
IP
|
$28.62
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
408114223
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.46 |
| Max. Negotiated Rate |
$26.61 |
| Rate for Payer: Aetna Commercial |
$24.72
|
| Rate for Payer: Aetna Commercial |
$19.31
|
| Rate for Payer: Cash Price |
$17.74
|
| Rate for Payer: Cash Price |
$13.85
|
| Rate for Payer: Cigna All Commercial |
$19.28
|
| Rate for Payer: Cigna All Commercial |
$24.70
|
| Rate for Payer: CORVEL All Commercial |
$26.61
|
| Rate for Payer: CORVEL All Commercial |
$20.78
|
| Rate for Payer: Coventry All Commercial |
$19.66
|
| Rate for Payer: Coventry All Commercial |
$25.18
|
| Rate for Payer: Encore All Commercial |
$26.34
|
| Rate for Payer: Encore All Commercial |
$20.57
|
| Rate for Payer: Frontpath All Commercial |
$20.56
|
| Rate for Payer: Frontpath All Commercial |
$26.33
|
| Rate for Payer: Humana ChoiceCare |
$24.72
|
| Rate for Payer: Humana ChoiceCare |
$19.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$20.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.75
|
| Rate for Payer: PHCS All Commercial |
$21.46
|
| Rate for Payer: PHCS All Commercial |
$16.76
|
| Rate for Payer: PHP All Commercial |
$16.95
|
| Rate for Payer: PHP All Commercial |
$21.70
|
| Rate for Payer: Sagamore Health Network All Products |
$22.09
|
| Rate for Payer: Sagamore Health Network All Products |
$17.25
|
| Rate for Payer: Signature Care EPO |
$23.75
|
| Rate for Payer: Signature Care EPO |
$18.55
|
| Rate for Payer: Signature Care PPO |
$19.66
|
| Rate for Payer: Signature Care PPO |
$25.18
|
| Rate for Payer: United Healthcare Commercial |
$17.61
|
| Rate for Payer: United Healthcare Commercial |
$22.55
|
|
|
HYDROMORPHONE 1 MG/ML INJ SYRG
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
114223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| 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 |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| 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 |
$5.94
|
|
|
HYDROMORPHONE 1 MG/ML INJ SYRG
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1170
|
| 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 |
$11.16
|
| 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 2 MG ORAL TAB
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 42858030101
|
| Hospital Charge Code |
3760
|
|
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
|
|
|
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 |
$2.48
|
| 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
|
|
|
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 |
$2.48
|
| 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
|
|
|
HYDROMORPHONE 4 MG ORAL TAB
|
Facility
OP
|
$4.00
|
|
|
Service Code
|
NDC 42858030201
|
| Hospital Charge Code |
3761
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| 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
|
|
|
HYDROMORPHONE 6 MG/30 ML (0.2 MG/ML) PCA (CAMERON)
|
Facility
IP
|
$104.58
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
1401000152453
|
|
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 |
$64.84
|
| 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
|
|
