Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

hydroxychloroquine 200 mg Tab [HMC]

Facility

OP

$18.08

Service Code	NDC 68382009601
Hospital Charge Code	3801848
Hospital Revenue Code	250
Min. Negotiated Rate	$7.23
Max. Negotiated Rate	$17.18
Rate for Payer: Aetna Commercial	$16.27
Rate for Payer: Humana Medicare Advantage	$7.59
Rate for Payer: UnitedHealthcare Commercial	$17.18
Rate for Payer: UnitedHealthcare Medicaid	$7.23
Rate for Payer: WPPA Medicare Advantage	$10.85

hydroxychloroquine 200 mg Tab [HMC]

Facility

IP

$9.55

Service Code	NDC 00904704606
Hospital Charge Code	3801848
Hospital Revenue Code	250
Min. Negotiated Rate	$8.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.60
Rate for Payer: UnitedHealthcare Commercial	$9.07
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydroxychloroquine 200 mg Tab [HMC]

Facility

IP

$10.00

Service Code	NDC 00904704661
Hospital Charge Code	3801848
Hospital Revenue Code	250
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.00
Rate for Payer: UnitedHealthcare Commercial	$9.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydroxychloroquine 200 mg Tab [HMC]

Facility

OP

$10.00

Service Code	NDC 00904704661
Hospital Charge Code	3801848
Hospital Revenue Code	250
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$9.50
Rate for Payer: Aetna Commercial	$9.00
Rate for Payer: Humana Medicare Advantage	$4.20
Rate for Payer: UnitedHealthcare Commercial	$9.50
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: WPPA Medicare Advantage	$6.00

hydroxychloroquine 200 mg Tab [HMC]

Facility

IP

$18.08

Service Code	NDC 68382009601
Hospital Charge Code	3801848
Hospital Revenue Code	250
Min. Negotiated Rate	$16.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.27
Rate for Payer: UnitedHealthcare Commercial	$17.18
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydroxychloroquine 200 mg Tab [HMC]

Facility

OP

$9.55

Service Code	NDC 00904704606
Hospital Charge Code	3801848
Hospital Revenue Code	250
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$9.07
Rate for Payer: Aetna Commercial	$8.60
Rate for Payer: Humana Medicare Advantage	$4.01
Rate for Payer: UnitedHealthcare Commercial	$9.07
Rate for Payer: UnitedHealthcare Medicaid	$3.82
Rate for Payer: WPPA Medicare Advantage	$5.73

hydroxychloroquine 200 mg Tab [HMC]

Facility

IP

$18.17

Service Code	NDC 68084026901
Hospital Charge Code	3801848
Hospital Revenue Code	250
Min. Negotiated Rate	$16.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.35
Rate for Payer: UnitedHealthcare Commercial	$17.26
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydroxychloroquine 200 mg Tab [HMC]

Facility

OP

$18.17

Service Code	NDC 68084026901
Hospital Charge Code	3801848
Hospital Revenue Code	250
Min. Negotiated Rate	$7.27
Max. Negotiated Rate	$17.26
Rate for Payer: Aetna Commercial	$16.35
Rate for Payer: Humana Medicare Advantage	$7.63
Rate for Payer: UnitedHealthcare Commercial	$17.26
Rate for Payer: UnitedHealthcare Medicaid	$7.27
Rate for Payer: WPPA Medicare Advantage	$10.90

Hydroxyindoleacetic Acid, 5-,U24 QST

Facility

IP

$89.00

Service Code	HCPCS 83497
Hospital Charge Code	3553497
Hospital Revenue Code	300
Min. Negotiated Rate	$80.10
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: UnitedHealthcare Commercial	$84.55
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Hydroxyindoleacetic Acid, 5-,U24 QST

Facility

OP

$89.00

Service Code	HCPCS 83497
Hospital Charge Code	3553497
Hospital Revenue Code	300
Min. Negotiated Rate	$12.90
Max. Negotiated Rate	$84.55
Rate for Payer: Aetna Commercial	$80.10
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$48.15
Rate for Payer: Humana Medicare Advantage	$37.38
Rate for Payer: UnitedHealthcare Commercial	$84.55
Rate for Payer: UnitedHealthcare Medicaid	$12.90
Rate for Payer: WPPA Medicare Advantage	$53.40

hydroxyprogesterone 250 mg/mL IM Sol [HMC]

Facility

IP

$6,230.00

Service Code	HCPCS J1729
Hospital Charge Code	3801910
Hospital Revenue Code	250
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$5,918.50
Rate for Payer: Aetna Commercial	$5,607.00
Rate for Payer: UnitedHealthcare Commercial	$5,918.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydroxyprogesterone 250 mg/mL IM Sol [HMC]

Facility

OP

$6,230.00

Service Code	HCPCS J1729
Hospital Charge Code	3801910
Hospital Revenue Code	250
Min. Negotiated Rate	$18.71
Max. Negotiated Rate	$5,918.50
Rate for Payer: Aetna Commercial	$5,607.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$18.71
Rate for Payer: Humana Medicare Advantage	$2,616.60
Rate for Payer: UnitedHealthcare Commercial	$5,918.50
Rate for Payer: WPPA Medicare Advantage	$3,738.00

hydroxyurea 500 mg Cap [HMC]

Facility

IP

$9.42

Service Code	HCPCS S0176
Hospital Charge Code	3802279
Hospital Revenue Code	250
Min. Negotiated Rate	$8.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.48
Rate for Payer: Aetna Commercial	$7.62
Rate for Payer: UnitedHealthcare Commercial	$8.05
Rate for Payer: UnitedHealthcare Commercial	$8.95
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydroxyurea 500 mg Cap [HMC]

Facility

OP

$8.47

Service Code	HCPCS S0176
Hospital Charge Code	3802279
Hospital Revenue Code	250
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$8.05
Rate for Payer: Aetna Commercial	$7.62
Rate for Payer: Aetna Commercial	$8.48
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$1.30
Rate for Payer: Humana Medicare Advantage	$3.96
Rate for Payer: Humana Medicare Advantage	$3.56
Rate for Payer: UnitedHealthcare Commercial	$8.95
Rate for Payer: UnitedHealthcare Commercial	$8.05
Rate for Payer: UnitedHealthcare Medicaid	$3.39
Rate for Payer: UnitedHealthcare Medicaid	$3.77
Rate for Payer: WPPA Medicare Advantage	$5.65
Rate for Payer: WPPA Medicare Advantage	$5.08

hydrOXYzine hydrochloride 10 mg Tab [HMC]

Facility

OP

$6.95

Service Code	NDC 00093506001
Hospital Charge Code	3806822
Hospital Revenue Code	250
Min. Negotiated Rate	$2.78
Max. Negotiated Rate	$6.60
Rate for Payer: Aetna Commercial	$6.25
Rate for Payer: Humana Medicare Advantage	$2.92
Rate for Payer: UnitedHealthcare Commercial	$6.60
Rate for Payer: UnitedHealthcare Medicaid	$2.78
Rate for Payer: WPPA Medicare Advantage	$4.17

hydrOXYzine hydrochloride 10 mg Tab [HMC]

Facility

OP

$5.88

Service Code	NDC 60687066401
Hospital Charge Code	3806822
Hospital Revenue Code	250
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$5.59
Rate for Payer: Aetna Commercial	$5.29
Rate for Payer: Humana Medicare Advantage	$2.47
Rate for Payer: UnitedHealthcare Commercial	$5.59
Rate for Payer: UnitedHealthcare Medicaid	$2.35
Rate for Payer: WPPA Medicare Advantage	$3.53

hydrOXYzine hydrochloride 10 mg Tab [HMC]

Facility

IP

$5.86

Service Code	NDC 63739048310
Hospital Charge Code	3806822
Hospital Revenue Code	250
Min. Negotiated Rate	$5.27
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.27
Rate for Payer: UnitedHealthcare Commercial	$5.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydrOXYzine hydrochloride 10 mg Tab [HMC]

Facility

IP

$6.95

Service Code	NDC 00093506001
Hospital Charge Code	3806822
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.25
Rate for Payer: UnitedHealthcare Commercial	$6.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydrOXYzine hydrochloride 10 mg Tab [HMC]

Facility

OP

$5.86

Service Code	NDC 63739048310
Hospital Charge Code	3806822
Hospital Revenue Code	250
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$5.57
Rate for Payer: Aetna Commercial	$5.27
Rate for Payer: Humana Medicare Advantage	$2.46
Rate for Payer: UnitedHealthcare Commercial	$5.57
Rate for Payer: UnitedHealthcare Medicaid	$2.34
Rate for Payer: WPPA Medicare Advantage	$3.52

hydrOXYzine hydrochloride 10 mg Tab [HMC]

Facility

IP

$5.88

Service Code	NDC 60687066401
Hospital Charge Code	3806822
Hospital Revenue Code	250
Min. Negotiated Rate	$5.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.29
Rate for Payer: UnitedHealthcare Commercial	$5.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydrOXYzine hydrochloride 25 mg Tab [HMC]

Facility

OP

$6.18

Service Code	NDC 60687067501
Hospital Charge Code	3804827
Hospital Revenue Code	250
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$5.87
Rate for Payer: Aetna Commercial	$5.56
Rate for Payer: Humana Medicare Advantage	$2.60
Rate for Payer: UnitedHealthcare Commercial	$5.87
Rate for Payer: UnitedHealthcare Medicaid	$2.47
Rate for Payer: WPPA Medicare Advantage	$3.71

hydrOXYzine hydrochloride 25 mg Tab [HMC]

Facility

IP

$5.91

Service Code	NDC 00904661761
Hospital Charge Code	3804827
Hospital Revenue Code	250
Min. Negotiated Rate	$5.32
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.32
Rate for Payer: UnitedHealthcare Commercial	$5.61
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydrOXYzine hydrochloride 25 mg Tab [HMC]

Facility

OP

$7.74

Service Code	NDC 50111030801
Hospital Charge Code	3804827
Hospital Revenue Code	250
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$7.35
Rate for Payer: Aetna Commercial	$6.97
Rate for Payer: Humana Medicare Advantage	$3.25
Rate for Payer: UnitedHealthcare Commercial	$7.35
Rate for Payer: UnitedHealthcare Medicaid	$3.10
Rate for Payer: WPPA Medicare Advantage	$4.64

hydrOXYzine hydrochloride 25 mg Tab [HMC]

Facility

IP

$7.74

Service Code	NDC 50111030801
Hospital Charge Code	3804827
Hospital Revenue Code	250
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.97
Rate for Payer: UnitedHealthcare Commercial	$7.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

hydrOXYzine hydrochloride 25 mg Tab [HMC]

Facility

OP

$7.74

Service Code	NDC 00093506101
Hospital Charge Code	3804827
Hospital Revenue Code	250
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$7.35
Rate for Payer: Aetna Commercial	$6.97
Rate for Payer: Humana Medicare Advantage	$3.25
Rate for Payer: UnitedHealthcare Commercial	$7.35
Rate for Payer: UnitedHealthcare Medicaid	$3.10
Rate for Payer: WPPA Medicare Advantage	$4.64

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