|
acetaminophen 160 mg/5 mL Oral Susp [HMC]
|
Facility
|
OP
|
$12.28
|
|
|
Service Code
|
NDC 00904727870
|
| Hospital Charge Code |
3804040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$11.67 |
| Rate for Payer: Aetna Commercial |
$11.05
|
| Rate for Payer: Humana Medicare Advantage |
$5.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.91
|
| Rate for Payer: WPPA Medicare Advantage |
$7.37
|
|
|
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
|
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
|
IP
|
$12.28
|
|
|
Service Code
|
NDC 00904727870
|
| Hospital Charge Code |
3804040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$11.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.67
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
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 325 mg Tab [HMC]
|
Facility
|
OP
|
$5.19
|
|
|
Service Code
|
NDC 00904677361
|
| Hospital Charge Code |
3804065
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$4.93 |
| Rate for Payer: Aetna Commercial |
$4.67
|
| Rate for Payer: Humana Medicare Advantage |
$2.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.08
|
| Rate for Payer: WPPA Medicare Advantage |
$3.11
|
|
|
acetaminophen 325 mg Tab [HMC]
|
Facility
|
IP
|
$5.17
|
|
|
Service Code
|
NDC 63739008702
|
| Hospital Charge Code |
3804065
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.65
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.91
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 325 mg Tab [HMC]
|
Facility
|
OP
|
$5.17
|
|
|
Service Code
|
NDC 63739008702
|
| Hospital Charge Code |
3804065
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$4.91 |
| Rate for Payer: Aetna Commercial |
$4.65
|
| Rate for Payer: Humana Medicare Advantage |
$2.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.07
|
| Rate for Payer: WPPA Medicare Advantage |
$3.10
|
|
|
acetaminophen 325 mg Tab [HMC]
|
Facility
|
IP
|
$5.19
|
|
|
Service Code
|
NDC 00904677361
|
| Hospital Charge Code |
3804065
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.67 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.93
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 500 mg Tab [HMC]
|
Facility
|
IP
|
$5.13
|
|
|
Service Code
|
NDC 00904673061
|
| Hospital Charge Code |
3804397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.62
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.87
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 500 mg Tab [HMC]
|
Facility
|
OP
|
$5.06
|
|
|
Service Code
|
NDC 00904672040
|
| Hospital Charge Code |
3804397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$4.81 |
| Rate for Payer: Aetna Commercial |
$4.55
|
| Rate for Payer: Humana Medicare Advantage |
$2.13
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.02
|
| Rate for Payer: WPPA Medicare Advantage |
$3.04
|
|
|
acetaminophen 500 mg Tab [HMC]
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 00536117201
|
| Hospital Charge Code |
3804397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.60 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.85
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 500 mg Tab [HMC]
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 00536117201
|
| Hospital Charge Code |
3804397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Aetna Commercial |
$4.60
|
| Rate for Payer: Humana Medicare Advantage |
$2.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.04
|
| Rate for Payer: WPPA Medicare Advantage |
$3.07
|
|
|
acetaminophen 500 mg Tab [HMC]
|
Facility
|
IP
|
$5.06
|
|
|
Service Code
|
NDC 00904672040
|
| Hospital Charge Code |
3804397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.81
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 500 mg Tab [HMC]
|
Facility
|
OP
|
$5.13
|
|
|
Service Code
|
NDC 00904673061
|
| Hospital Charge Code |
3804397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$4.87 |
| Rate for Payer: Aetna Commercial |
$4.62
|
| Rate for Payer: Humana Medicare Advantage |
$2.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.05
|
| Rate for Payer: WPPA Medicare Advantage |
$3.08
|
|
|
acetaminophen 650 mg ER Tab [HMC]
|
Facility
|
OP
|
$5.31
|
|
|
Service Code
|
NDC 49483069901
|
| Hospital Charge Code |
3803869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Aetna Commercial |
$4.78
|
| Rate for Payer: Humana Medicare Advantage |
$2.23
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.12
|
| Rate for Payer: WPPA Medicare Advantage |
$3.19
|
|
|
acetaminophen 650 mg ER Tab [HMC]
|
Facility
|
IP
|
$7.95
|
|
|
Service Code
|
NDC 50268005215
|
| Hospital Charge Code |
3803869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.55
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 650 mg ER Tab [HMC]
|
Facility
|
IP
|
$5.31
|
|
|
Service Code
|
NDC 49483069901
|
| Hospital Charge Code |
3803869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.78
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.04
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 650 mg ER Tab [HMC]
|
Facility
|
OP
|
$7.95
|
|
|
Service Code
|
NDC 50268005215
|
| Hospital Charge Code |
3803869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$7.55 |
| Rate for Payer: Aetna Commercial |
$7.16
|
| Rate for Payer: Humana Medicare Advantage |
$3.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.18
|
| Rate for Payer: WPPA Medicare Advantage |
$4.77
|
|
|
acetaminophen 650 mg ER Tab [HMC]
|
Facility
|
IP
|
$5.27
|
|
|
Service Code
|
NDC 00904576960
|
| Hospital Charge Code |
3803869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.01
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 650 mg ER Tab [HMC]
|
Facility
|
OP
|
$5.27
|
|
|
Service Code
|
NDC 00904576960
|
| Hospital Charge Code |
3803869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$5.01 |
| Rate for Payer: Aetna Commercial |
$4.74
|
| Rate for Payer: Humana Medicare Advantage |
$2.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.11
|
| Rate for Payer: WPPA Medicare Advantage |
$3.16
|
|
|
acetaminophen 650 mg Supp [HMC]
|
Facility
|
OP
|
$6.29
|
|
|
Service Code
|
NDC 45802073033
|
| Hospital Charge Code |
3805360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$5.98 |
| Rate for Payer: Aetna Commercial |
$5.66
|
| Rate for Payer: Humana Medicare Advantage |
$2.64
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.52
|
| Rate for Payer: WPPA Medicare Advantage |
$3.77
|
|
|
acetaminophen 650 mg Supp [HMC]
|
Facility
|
OP
|
$6.78
|
|
|
Service Code
|
NDC 45802073032
|
| Hospital Charge Code |
3805360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.10
|
| Rate for Payer: Humana Medicare Advantage |
$2.85
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.71
|
| Rate for Payer: WPPA Medicare Advantage |
$4.07
|
|
|
acetaminophen 650 mg Supp [HMC]
|
Facility
|
IP
|
$6.29
|
|
|
Service Code
|
NDC 45802073033
|
| Hospital Charge Code |
3805360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.66
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.98
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen 650 mg Supp [HMC]
|
Facility
|
IP
|
$6.78
|
|
|
Service Code
|
NDC 45802073032
|
| Hospital Charge Code |
3805360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.10 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.44
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
