|
Ace Bandage 4 X 5 yd
|
Facility
|
OP
|
$2.50
|
|
| Hospital Charge Code |
3250201
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: Humana Medicare Advantage |
$1.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1.50
|
|
|
Ace Bandage 4 X 5 yd
|
Facility
|
IP
|
$2.50
|
|
| Hospital Charge Code |
3250201
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.38
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Ace Bandage 6 X 10 yd Sterile
|
Facility
|
OP
|
$14.40
|
|
| Hospital Charge Code |
3250220
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.76 |
| Max. Negotiated Rate |
$13.68 |
| Rate for Payer: Aetna Commercial |
$12.96
|
| Rate for Payer: Humana Medicare Advantage |
$6.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.76
|
| Rate for Payer: WPPA Medicare Advantage |
$8.64
|
|
|
Ace Bandage 6 X 10 yd Sterile
|
Facility
|
IP
|
$14.40
|
|
| Hospital Charge Code |
3250220
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.96 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$12.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.68
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Ace Bandage 6 X 5 yd
|
Facility
|
OP
|
$2.88
|
|
| Hospital Charge Code |
3250219
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: Humana Medicare Advantage |
$1.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.15
|
| Rate for Payer: WPPA Medicare Advantage |
$1.73
|
|
|
Ace Bandage 6 X 5 yd
|
Facility
|
IP
|
$2.88
|
|
| Hospital Charge Code |
3250219
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.59 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.74
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 10 mg/mL [HMC]
|
Facility
|
IP
|
$95.27
|
|
|
Service Code
|
HCPCS J0131
|
| Hospital Charge Code |
3800126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.74 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$85.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$90.51
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 10 mg/mL [HMC]
|
Facility
|
OP
|
$95.27
|
|
|
Service Code
|
HCPCS J0131
|
| Hospital Charge Code |
3800126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$90.51 |
| Rate for Payer: Aetna Commercial |
$85.74
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.06
|
| Rate for Payer: Humana Medicare Advantage |
$40.01
|
| Rate for Payer: UnitedHealthcare Commercial |
$90.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.06
|
| Rate for Payer: WPPA Medicare Advantage |
$57.16
|
|
|
acetaminophen 10 mg/mL Sol [HMC]
|
Facility
|
IP
|
$49.60
|
|
|
Service Code
|
HCPCS J0131
|
| Hospital Charge Code |
3800126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.64 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$44.64
|
| Rate for Payer: Aetna Commercial |
$88.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$93.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$47.12
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 10 mg/mL Sol [HMC]
|
Facility
|
OP
|
$49.60
|
|
|
Service Code
|
HCPCS J0131
|
| Hospital Charge Code |
3800126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$47.12 |
| Rate for Payer: Aetna Commercial |
$44.64
|
| Rate for Payer: Aetna Commercial |
$88.94
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.06
|
| Rate for Payer: Humana Medicare Advantage |
$41.50
|
| Rate for Payer: Humana Medicare Advantage |
$20.83
|
| Rate for Payer: UnitedHealthcare Commercial |
$93.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$47.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.06
|
| Rate for Payer: WPPA Medicare Advantage |
$29.76
|
| Rate for Payer: WPPA Medicare Advantage |
$59.29
|
|
|
acetaminophen 120 mg Supp [HMC]
|
Facility
|
IP
|
$6.75
|
|
|
Service Code
|
NDC 45802073230
|
| Hospital Charge Code |
3806244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.41
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 120 mg Supp [HMC]
|
Facility
|
OP
|
$6.75
|
|
|
Service Code
|
NDC 45802073230
|
| Hospital Charge Code |
3806244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$6.41 |
| Rate for Payer: Aetna Commercial |
$6.08
|
| Rate for Payer: Humana Medicare Advantage |
$2.83
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.70
|
| Rate for Payer: WPPA Medicare Advantage |
$4.05
|
|
|
acetaminophen 120 mg Supp [HMC]
|
Facility
|
OP
|
$6.11
|
|
|
Service Code
|
NDC 45802073233
|
| Hospital Charge Code |
3806244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.44 |
| Max. Negotiated Rate |
$5.80 |
| Rate for Payer: Aetna Commercial |
$5.50
|
| Rate for Payer: Humana Medicare Advantage |
$2.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.44
|
| Rate for Payer: WPPA Medicare Advantage |
$3.67
|
|
|
acetaminophen 120 mg Supp [HMC]
|
Facility
|
IP
|
$6.11
|
|
|
Service Code
|
NDC 45802073233
|
| Hospital Charge Code |
3806244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 160 mg/5 mL Oral Sus [HMC]
|
Facility
|
OP
|
$12.34
|
|
|
Service Code
|
NDC 68094023162
|
| Hospital Charge Code |
3804040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.94 |
| Max. Negotiated Rate |
$11.72 |
| Rate for Payer: Aetna Commercial |
$11.11
|
| Rate for Payer: Humana Medicare Advantage |
$5.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.94
|
| Rate for Payer: WPPA Medicare Advantage |
$7.40
|
|
|
acetaminophen 160 mg/5 mL Oral Sus [HMC]
|
Facility
|
IP
|
$12.34
|
|
|
Service Code
|
NDC 68094023162
|
| Hospital Charge Code |
3804040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.11 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$11.11
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.72
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 160 mg/5 mL Oral Susp [HMC]
|
Facility
|
IP
|
$11.27
|
|
|
Service Code
|
NDC 68094059362
|
| Hospital Charge Code |
3804040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.71
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 160 mg/5 mL Oral Susp [HMC]
|
Facility
|
OP
|
$11.27
|
|
|
Service Code
|
NDC 68094059362
|
| Hospital Charge Code |
3804040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.51 |
| Max. Negotiated Rate |
$10.71 |
| Rate for Payer: Aetna Commercial |
$10.14
|
| Rate for Payer: Humana Medicare Advantage |
$4.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.51
|
| Rate for Payer: WPPA Medicare Advantage |
$6.76
|
|
|
acetaminophen 160 mg/5 mL Oral Susp [HMC]
|
Facility
|
IP
|
$12.78
|
|
|
Service Code
|
NDC 00121178105
|
| Hospital Charge Code |
3804040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$11.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.14
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 160 mg/5 mL Oral Susp [HMC]
|
Facility
|
OP
|
$12.84
|
|
|
Service Code
|
NDC 00121096600
|
| Hospital Charge Code |
3804040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.14 |
| Max. Negotiated Rate |
$12.20 |
| Rate for Payer: Aetna Commercial |
$11.56
|
| Rate for Payer: Humana Medicare Advantage |
$5.39
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.14
|
| Rate for Payer: WPPA Medicare Advantage |
$7.70
|
|
|
acetaminophen 160 mg/5 mL Oral Susp [HMC]
|
Facility
|
OP
|
$10.62
|
|
|
Service Code
|
NDC 50580061401
|
| Hospital Charge Code |
3804040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$10.09 |
| Rate for Payer: Aetna Commercial |
$9.56
|
| Rate for Payer: Humana Medicare Advantage |
$4.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.25
|
| Rate for Payer: WPPA Medicare Advantage |
$6.37
|
|
|
acetaminophen 160 mg/5 mL Oral Susp [HMC]
|
Facility
|
OP
|
$10.26
|
|
|
Service Code
|
NDC 45802020126
|
| Hospital Charge Code |
3804040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.10 |
| Max. Negotiated Rate |
$9.75 |
| Rate for Payer: Aetna Commercial |
$9.23
|
| Rate for Payer: Humana Medicare Advantage |
$4.31
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.10
|
| Rate for Payer: WPPA Medicare Advantage |
$6.16
|
|
|
acetaminophen 160 mg/5 mL Oral Susp [HMC]
|
Facility
|
IP
|
$12.78
|
|
|
Service Code
|
NDC 00121178100
|
| Hospital Charge Code |
3804040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$11.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.14
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 160 mg/5 mL Oral Susp [HMC]
|
Facility
|
IP
|
$10.62
|
|
|
Service Code
|
NDC 50580061401
|
| Hospital Charge Code |
3804040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.56
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.09
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 160 mg/5 mL Oral Susp [HMC]
|
Facility
|
OP
|
$12.78
|
|
|
Service Code
|
NDC 00121178105
|
| Hospital Charge Code |
3804040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.11 |
| Max. Negotiated Rate |
$12.14 |
| Rate for Payer: Aetna Commercial |
$11.50
|
| Rate for Payer: Humana Medicare Advantage |
$5.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.11
|
| Rate for Payer: WPPA Medicare Advantage |
$7.67
|
|
