|
HYDROCLORTHIAZIDE 12.5MG CAP EMP
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 2.93E+10
|
| Hospital Charge Code |
2625421
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$14.40
|
|
|
HYDROCO/APAP 10/325MG TAB EMP C2
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
NDC 591261201
|
| Hospital Charge Code |
2619993
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$28.56 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$23.68
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$28.56
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.68
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$14.40
|
|
|
HYDROCO/APAP 10/325MG TAB EMP C2
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
NDC 591261201
|
| Hospital Charge Code |
2619993
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$36.00
|
|
|
HYDROCO/APAP 5/216MG OR SOL 10ML C2
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
NDC 6.4376E+10
|
| Hospital Charge Code |
2698042
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.28 |
| Max. Negotiated Rate |
$34.27 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$28.42
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$34.27
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$32.02
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$17.28
|
|
|
HYDROCO/APAP 5/216MG OR SOL 10ML C2
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
NDC 6.4376E+10
|
| Hospital Charge Code |
2698042
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$43.20
|
|
|
HYDROCO/APAP 5/325MG TAB EMP C2
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 4.2858E+10
|
| Hospital Charge Code |
2626311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$14.28 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$11.84
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.28
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.34
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.20
|
|
|
HYDROCO/APAP 5/325MG TAB EMP C2
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 4.2858E+10
|
| Hospital Charge Code |
2626311
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.00
|
|
|
HYDROCO/APAP 7.5/325MG TAB EMP C2
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 406012401
|
| Hospital Charge Code |
2698049
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$19.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$16.58
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$19.99
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.68
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$10.08
|
|
|
HYDROCO/APAP 7.5/325MG TAB EMP C2
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 406012401
|
| Hospital Charge Code |
2698049
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$25.20
|
|
|
HYDROCO/APAP (NORCO) 10/325MG TAB C2
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
NDC 406012523
|
| Hospital Charge Code |
2697098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$28.56 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$23.68
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$28.56
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.68
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$14.40
|
|
|
HYDROCO/APAP (NORCO) 10/325MG TAB C2
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
NDC 406012523
|
| Hospital Charge Code |
2697098
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$36.00
|
|
|
HYDROCO/APAP (NORCO) 5/325MG TAB UD C2
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 904682461
|
| Hospital Charge Code |
2697571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$14.28 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$11.84
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.28
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.34
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.20
|
|
|
HYDROCO/APAP (NORCO) 5/325MG TAB UD C2
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 904682461
|
| Hospital Charge Code |
2697571
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.00
|
|
|
HYDROCO/APAP (NORCO) 7.5/325MG TAB C2
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 406012401
|
| Hospital Charge Code |
2697097
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$19.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$16.58
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$19.99
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.68
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$10.08
|
|
|
HYDROCO/APAP (NORCO) 7.5/325MG TAB C2
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 406012401
|
| Hospital Charge Code |
2697097
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$25.20
|
|
|
HYDROCOD/APAP (LORCET) 10/650MG TAB
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 406036701
|
| Hospital Charge Code |
2655443
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.48 |
| Max. Negotiated Rate |
$12.85 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$10.66
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$12.85
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$6.48
|
|
|
HYDROCOD/APAP (LORCET) 10/650MG TAB
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 406036701
|
| Hospital Charge Code |
2655443
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$16.20
|
|
|
HYDROCODONE
|
Facility
|
OP
|
$396.00
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
2282646
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$282.74 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$234.43
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$282.74
|
| Rate for Payer: Cash Price |
$356.40
|
| Rate for Payer: Cash Price |
$356.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$21.00
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$142.56
|
|
|
HYDROCODONE
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
2282646
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$356.40
|
|
|
HYDROCODONE/APAP (LORCET PLUS) 7.5/650 T
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 5.3746E+10
|
| Hospital Charge Code |
2654254
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$7.70
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$9.28
|
| Rate for Payer: Cash Price |
$11.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.67
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$4.68
|
|
|
HYDROCODONE/APAP (LORCET PLUS) 7.5/650 T
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 5.3746E+10
|
| Hospital Charge Code |
2654254
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$11.70
|
|
|
HYDROCODONE/APAP (VICODIN)5/500 TAB
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 406035701
|
| Hospital Charge Code |
2626326
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$8.10
|
|
|
HYDROCODONE/APAP (VICODIN)5/500 TAB
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 406035701
|
| Hospital Charge Code |
2626326
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$5.33
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$6.43
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.00
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$3.24
|
|
|
HYDROCORTISONE 100MG/2ML INJ EMP
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
2624391
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$111.60
|
|
|
HYDROCORTISONE 100MG/2ML INJ EMP
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
2624391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.64 |
| Max. Negotiated Rate |
$88.54 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$73.41
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$88.54
|
| Rate for Payer: Cash Price |
$111.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$82.71
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$44.64
|
|
