|
acetaminophen-HYDROcodone 325 mg-5 mg Tab [HMC]
|
Facility
|
OP
|
$7.07
|
|
|
Service Code
|
NDC 27808003501
|
| Hospital Charge Code |
3802248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$6.72 |
| Rate for Payer: Aetna Commercial |
$6.36
|
| Rate for Payer: Humana Medicare Advantage |
$2.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.83
|
| Rate for Payer: WPPA Medicare Advantage |
$4.24
|
|
|
acetaminophen-HYDROcodone 325 mg-5 mg Tab [HMC]
|
Facility
|
IP
|
$7.06
|
|
|
Service Code
|
NDC 68084089509
|
| Hospital Charge Code |
3802248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.35 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.35
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.71
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen-HYDROcodone 325 mg-5 mg Tab [HMC]
|
Facility
|
IP
|
$7.39
|
|
|
Service Code
|
NDC 00406012362
|
| Hospital Charge Code |
3802248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.65 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.02
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen-HYDROcodone 325 mg-5 mg Tab [HMC]
|
Facility
|
OP
|
$7.06
|
|
|
Service Code
|
NDC 68084089509
|
| Hospital Charge Code |
3802248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$6.71 |
| Rate for Payer: Aetna Commercial |
$6.35
|
| Rate for Payer: Humana Medicare Advantage |
$2.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.82
|
| Rate for Payer: WPPA Medicare Advantage |
$4.24
|
|
|
acetaminophen-HYDROcodone 325 mg-5 mg Tab [HMC]
|
Facility
|
IP
|
$7.07
|
|
|
Service Code
|
NDC 27808003501
|
| Hospital Charge Code |
3802248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.72
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Oral Sol 118 mL [HMC]
|
Facility
|
IP
|
$19.82
|
|
|
Service Code
|
NDC 00121077204
|
| Hospital Charge Code |
3800160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.84 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$17.84
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.83
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Oral Sol 118 mL [HMC]
|
Facility
|
IP
|
$19.84
|
|
|
Service Code
|
NDC 64376064040
|
| Hospital Charge Code |
3800160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.86 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$17.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.85
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Oral Sol 118 mL [HMC]
|
Facility
|
OP
|
$19.84
|
|
|
Service Code
|
NDC 64376064040
|
| Hospital Charge Code |
3800160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.94 |
| Max. Negotiated Rate |
$18.85 |
| Rate for Payer: Aetna Commercial |
$17.86
|
| Rate for Payer: Humana Medicare Advantage |
$8.33
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.94
|
| Rate for Payer: WPPA Medicare Advantage |
$11.90
|
|
|
acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Oral Sol 118 mL [HMC]
|
Facility
|
OP
|
$19.82
|
|
|
Service Code
|
NDC 00121077204
|
| Hospital Charge Code |
3800160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$18.83 |
| Rate for Payer: Aetna Commercial |
$17.84
|
| Rate for Payer: Humana Medicare Advantage |
$8.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.93
|
| Rate for Payer: WPPA Medicare Advantage |
$11.89
|
|
|
acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL Sol 473 mL [HMC]
|
Facility
|
OP
|
$18.65
|
|
|
Service Code
|
NDC 66689002316
|
| Hospital Charge Code |
3800160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.46 |
| Max. Negotiated Rate |
$17.72 |
| Rate for Payer: Aetna Commercial |
$16.79
|
| Rate for Payer: Humana Medicare Advantage |
$7.83
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.46
|
| Rate for Payer: WPPA Medicare Advantage |
$11.19
|
|
|
acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL Sol 473 mL [HMC]
|
Facility
|
OP
|
$27.99
|
|
|
Service Code
|
NDC 64950034316
|
| Hospital Charge Code |
3800160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$26.59 |
| Rate for Payer: Aetna Commercial |
$25.19
|
| Rate for Payer: Humana Medicare Advantage |
$11.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.20
|
| Rate for Payer: WPPA Medicare Advantage |
$16.79
|
|
|
acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL Sol 473 mL [HMC]
|
Facility
|
IP
|
$27.99
|
|
|
Service Code
|
NDC 64950034316
|
| Hospital Charge Code |
3800160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.19 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.59
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL Sol 473 mL [HMC]
|
Facility
|
IP
|
$18.65
|
|
|
Service Code
|
NDC 66689002316
|
| Hospital Charge Code |
3800160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.79 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$16.79
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.72
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [HMC]
|
Facility
|
OP
|
$16.85
|
|
|
Service Code
|
NDC 50268040015
|
| Hospital Charge Code |
3802708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.74 |
| Max. Negotiated Rate |
$16.01 |
| Rate for Payer: Aetna Commercial |
$15.16
|
| Rate for Payer: Humana Medicare Advantage |
$7.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.74
|
| Rate for Payer: WPPA Medicare Advantage |
$10.11
|
|
|
acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [HMC]
|
Facility
|
OP
|
$17.66
|
|
|
Service Code
|
NDC 00406012462
|
| Hospital Charge Code |
3802708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$16.78 |
| Rate for Payer: Aetna Commercial |
$15.89
|
| Rate for Payer: Humana Medicare Advantage |
$7.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.06
|
| Rate for Payer: WPPA Medicare Advantage |
$10.60
|
|
|
acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [HMC]
|
Facility
|
IP
|
$17.66
|
|
|
Service Code
|
NDC 00406012462
|
| Hospital Charge Code |
3802708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.89 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$15.89
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.78
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [HMC]
|
Facility
|
IP
|
$17.31
|
|
|
Service Code
|
NDC 00603389121
|
| Hospital Charge Code |
3802708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.58 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$15.58
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.44
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [HMC]
|
Facility
|
OP
|
$17.31
|
|
|
Service Code
|
NDC 00603389121
|
| Hospital Charge Code |
3802708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.92 |
| Max. Negotiated Rate |
$16.44 |
| Rate for Payer: Aetna Commercial |
$15.58
|
| Rate for Payer: Humana Medicare Advantage |
$7.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.92
|
| Rate for Payer: WPPA Medicare Advantage |
$10.39
|
|
|
acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [HMC]
|
Facility
|
IP
|
$16.85
|
|
|
Service Code
|
NDC 50268040015
|
| Hospital Charge Code |
3802708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.16 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$15.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.01
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Acetaminophen Level
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
HCPCS 80143
|
| Hospital Charge Code |
3551675
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.84 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Aetna Commercial |
$167.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$29.09
|
| Rate for Payer: Humana Medicare Advantage |
$78.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$176.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.84
|
| Rate for Payer: WPPA Medicare Advantage |
$111.60
|
|
|
Acetaminophen Level
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
HCPCS 80143
|
| Hospital Charge Code |
3551675
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$167.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$167.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$176.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen-oxyCODONE 325 mg-10 mg Tab [HMC]
|
Facility
|
IP
|
$9.31
|
|
|
Service Code
|
NDC 00904709561
|
| Hospital Charge Code |
3801025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.38 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.84
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen-oxyCODONE 325 mg-10 mg Tab [HMC]
|
Facility
|
OP
|
$9.31
|
|
|
Service Code
|
NDC 00904709561
|
| Hospital Charge Code |
3801025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$8.84 |
| Rate for Payer: Aetna Commercial |
$8.38
|
| Rate for Payer: Humana Medicare Advantage |
$3.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.72
|
| Rate for Payer: WPPA Medicare Advantage |
$5.59
|
|
|
acetaminophen-oxyCODONE 325 mg-10 mg Tab [HMC]
|
Facility
|
IP
|
$15.65
|
|
|
Service Code
|
NDC 47781023005
|
| Hospital Charge Code |
3801025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.09 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$14.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.87
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
acetaminophen-oxyCODONE 325 mg-10 mg Tab [HMC]
|
Facility
|
OP
|
$15.65
|
|
|
Service Code
|
NDC 47781023005
|
| Hospital Charge Code |
3801025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.26 |
| Max. Negotiated Rate |
$14.87 |
| Rate for Payer: Aetna Commercial |
$14.09
|
| Rate for Payer: Humana Medicare Advantage |
$6.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.26
|
| Rate for Payer: WPPA Medicare Advantage |
$9.39
|
|
