Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

acetaminophen-oxycodone 325 mg-5 mg Tab [HMC]

Facility

OP

$9.16

Service Code	NDC 60687064201
Hospital Charge Code	3804942
Hospital Revenue Code	250
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$8.70
Rate for Payer: Aetna Commercial	$8.24
Rate for Payer: Humana Medicare Advantage	$3.85
Rate for Payer: UnitedHealthcare Commercial	$8.70
Rate for Payer: UnitedHealthcare Medicaid	$3.66
Rate for Payer: WPPA Medicare Advantage	$5.50

acetaminophen-oxycodone 325 mg-5 mg Tab [HMC]

Facility

IP

$9.16

Service Code	NDC 60687064201
Hospital Charge Code	3804942
Hospital Revenue Code	250
Min. Negotiated Rate	$8.24
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.24
Rate for Payer: UnitedHealthcare Commercial	$8.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acetaminophen-oxyCODONE 325 mg-5 mg Tab [HMC]

Facility

OP

$9.16

Service Code	NDC 68084035501
Hospital Charge Code	3804942
Hospital Revenue Code	250
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$8.70
Rate for Payer: Aetna Commercial	$8.24
Rate for Payer: Humana Medicare Advantage	$3.85
Rate for Payer: UnitedHealthcare Commercial	$8.70
Rate for Payer: UnitedHealthcare Medicaid	$3.66
Rate for Payer: WPPA Medicare Advantage	$5.50

acetaminophen-oxyCODONE 325 mg-5 mg Tab [HMC]

Facility

IP

$9.10

Service Code	NDC 50268064415
Hospital Charge Code	3804942
Hospital Revenue Code	250
Min. Negotiated Rate	$8.19
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.19
Rate for Payer: UnitedHealthcare Commercial	$8.64
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acetaminophen-oxyCODONE 325 mg-5 mg Tab [HMC]

Facility

IP

$6.01

Service Code	NDC 00904709361
Hospital Charge Code	3804942
Hospital Revenue Code	250
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.41
Rate for Payer: UnitedHealthcare Commercial	$5.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acetaminophen-oxyCODONE 325 mg-5 mg Tab [HMC]

Facility

OP

$9.11

Service Code	NDC 00406051201
Hospital Charge Code	3804942
Hospital Revenue Code	250
Min. Negotiated Rate	$3.64
Max. Negotiated Rate	$8.65
Rate for Payer: Aetna Commercial	$8.20
Rate for Payer: Humana Medicare Advantage	$3.83
Rate for Payer: UnitedHealthcare Commercial	$8.65
Rate for Payer: UnitedHealthcare Medicaid	$3.64
Rate for Payer: WPPA Medicare Advantage	$5.47

acetaminophen-oxyCODONE 325 mg-5 mg Tab [HMC]

Facility

IP

$9.16

Service Code	NDC 68084035501
Hospital Charge Code	3804942
Hospital Revenue Code	250
Min. Negotiated Rate	$8.24
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.24
Rate for Payer: UnitedHealthcare Commercial	$8.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acetaminophen-oxyCODONE 325 mg-5 mg Tab [HMC]

Facility

OP

$9.10

Service Code	NDC 50268064415
Hospital Charge Code	3804942
Hospital Revenue Code	250
Min. Negotiated Rate	$3.64
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.19
Rate for Payer: Humana Medicare Advantage	$3.82
Rate for Payer: UnitedHealthcare Commercial	$8.64
Rate for Payer: UnitedHealthcare Medicaid	$3.64
Rate for Payer: WPPA Medicare Advantage	$5.46

acetaminophen-oxyCODONE 325 mg-5 mg Tab [HMC]

Facility

OP

$6.01

Service Code	NDC 00904709361
Hospital Charge Code	3804942
Hospital Revenue Code	250
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$5.71
Rate for Payer: Aetna Commercial	$5.41
Rate for Payer: Humana Medicare Advantage	$2.52
Rate for Payer: UnitedHealthcare Commercial	$5.71
Rate for Payer: UnitedHealthcare Medicaid	$2.40
Rate for Payer: WPPA Medicare Advantage	$3.61

acetaminophen-oxyCODONE 325 mg-5 mg Tab [HMC]

Facility

OP

$9.11

Service Code	NDC 00406051262
Hospital Charge Code	3804942
Hospital Revenue Code	250
Min. Negotiated Rate	$3.64
Max. Negotiated Rate	$8.65
Rate for Payer: Aetna Commercial	$8.20
Rate for Payer: Humana Medicare Advantage	$3.83
Rate for Payer: UnitedHealthcare Commercial	$8.65
Rate for Payer: UnitedHealthcare Medicaid	$3.64
Rate for Payer: WPPA Medicare Advantage	$5.47

acetaminophen-oxyCODONE 325 mg-5 mg Tab [HMC]

Facility

IP

$9.11

Service Code	NDC 00406051262
Hospital Charge Code	3804942
Hospital Revenue Code	250
Min. Negotiated Rate	$8.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.20
Rate for Payer: UnitedHealthcare Commercial	$8.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acetaminophen-oxyCODONE 325 mg-5 mg Tab [HMC]

Facility

IP

$9.11

Service Code	NDC 00406051201
Hospital Charge Code	3804942
Hospital Revenue Code	250
Min. Negotiated Rate	$8.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$8.20
Rate for Payer: UnitedHealthcare Commercial	$8.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acetaZOLAMIDE 250 mg Tab [HMC]

Facility

OP

$13.65

Service Code	NDC 51672402301
Hospital Charge Code	3804297
Hospital Revenue Code	250
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$12.97
Rate for Payer: Aetna Commercial	$12.29
Rate for Payer: Humana Medicare Advantage	$5.73
Rate for Payer: UnitedHealthcare Commercial	$12.97
Rate for Payer: UnitedHealthcare Medicaid	$5.46
Rate for Payer: WPPA Medicare Advantage	$8.19

acetaZOLAMIDE 250 mg Tab [HMC]

Facility

OP

$13.65

Service Code	NDC 23155028801
Hospital Charge Code	3804297
Hospital Revenue Code	250
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$12.97
Rate for Payer: Aetna Commercial	$12.29
Rate for Payer: Humana Medicare Advantage	$5.73
Rate for Payer: UnitedHealthcare Commercial	$12.97
Rate for Payer: UnitedHealthcare Medicaid	$5.46
Rate for Payer: WPPA Medicare Advantage	$8.19

acetaZOLAMIDE 250 mg Tab [HMC]

Facility

IP

$13.65

Service Code	NDC 23155028801
Hospital Charge Code	3804297
Hospital Revenue Code	250
Min. Negotiated Rate	$12.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.29
Rate for Payer: UnitedHealthcare Commercial	$12.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acetaZOLAMIDE 250 mg Tab [HMC]

Facility

IP

$13.65

Service Code	NDC 51672402301
Hospital Charge Code	3804297
Hospital Revenue Code	250
Min. Negotiated Rate	$12.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$12.29
Rate for Payer: UnitedHealthcare Commercial	$12.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Acetylcholine Receptor Binding Ab QST

Facility

IP

$415.00

Service Code	HCPCS 86041
Hospital Charge Code	3552540-1
Hospital Revenue Code	300
Min. Negotiated Rate	$373.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$373.50
Rate for Payer: UnitedHealthcare Commercial	$394.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Acetylcholine Receptor Binding Ab QST

Facility

OP

$415.00

Service Code	HCPCS 86041
Hospital Charge Code	3552540-1
Hospital Revenue Code	300
Min. Negotiated Rate	$15.64
Max. Negotiated Rate	$394.25
Rate for Payer: Aetna Commercial	$373.50
Rate for Payer: Humana Medicare Advantage	$174.30
Rate for Payer: UnitedHealthcare Commercial	$394.25
Rate for Payer: UnitedHealthcare Medicaid	$15.64
Rate for Payer: WPPA Medicare Advantage	$249.00

Acetylcholine Receptor Blocking Ab QST

Facility

IP

$415.00

Service Code	HCPCS 86042
Hospital Charge Code	3552540-2
Hospital Revenue Code	300
Min. Negotiated Rate	$373.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$373.50
Rate for Payer: UnitedHealthcare Commercial	$394.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Acetylcholine Receptor Blocking Ab QST

Facility

OP

$415.00

Service Code	HCPCS 86042
Hospital Charge Code	3552540-2
Hospital Revenue Code	300
Min. Negotiated Rate	$15.64
Max. Negotiated Rate	$394.25
Rate for Payer: Aetna Commercial	$373.50
Rate for Payer: Humana Medicare Advantage	$174.30
Rate for Payer: UnitedHealthcare Commercial	$394.25
Rate for Payer: UnitedHealthcare Medicaid	$15.64
Rate for Payer: WPPA Medicare Advantage	$249.00

Acetylcholine Receptor Modulating Ab QST

Facility

IP

$415.00

Service Code	HCPCS 86043
Hospital Charge Code	3552540-3
Hospital Revenue Code	300
Min. Negotiated Rate	$373.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$373.50
Rate for Payer: UnitedHealthcare Commercial	$394.25
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Acetylcholine Receptor Modulating Ab QST

Facility

OP

$415.00

Service Code	HCPCS 86043
Hospital Charge Code	3552540-3
Hospital Revenue Code	300
Min. Negotiated Rate	$10.24
Max. Negotiated Rate	$394.25
Rate for Payer: Aetna Commercial	$373.50
Rate for Payer: Humana Medicare Advantage	$174.30
Rate for Payer: UnitedHealthcare Commercial	$394.25
Rate for Payer: UnitedHealthcare Medicaid	$10.24
Rate for Payer: WPPA Medicare Advantage	$249.00

acetylcysteine 20% Inh Sol 30 mL [HMC]

Facility

IP

$35.25

Service Code	HCPCS J7608
Hospital Charge Code	3800103
Hospital Revenue Code	250
Min. Negotiated Rate	$31.73
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.73
Rate for Payer: Aetna Commercial	$46.93
Rate for Payer: UnitedHealthcare Commercial	$49.53
Rate for Payer: UnitedHealthcare Commercial	$33.49
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

acetylcysteine 20% Inh Sol 30 mL [HMC]

Facility

OP

$35.25

Service Code	HCPCS J7608
Hospital Charge Code	3800103
Hospital Revenue Code	250
Min. Negotiated Rate	$8.46
Max. Negotiated Rate	$33.49
Rate for Payer: Aetna Commercial	$31.73
Rate for Payer: Aetna Commercial	$46.93
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$12.04
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$12.04
Rate for Payer: Humana Medicare Advantage	$21.90
Rate for Payer: Humana Medicare Advantage	$14.80
Rate for Payer: UnitedHealthcare Commercial	$49.53
Rate for Payer: UnitedHealthcare Commercial	$33.49
Rate for Payer: UnitedHealthcare Medicaid	$8.46
Rate for Payer: UnitedHealthcare Medicaid	$8.46
Rate for Payer: WPPA Medicare Advantage	$31.28
Rate for Payer: WPPA Medicare Advantage	$21.15

acetylcysteine 20% Inh Sol 4 mL [HMC]

Facility

IP

$34.88

Service Code	HCPCS J7608
Hospital Charge Code	3805840
Hospital Revenue Code	250
Min. Negotiated Rate	$31.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.39
Rate for Payer: Aetna Commercial	$34.88
Rate for Payer: UnitedHealthcare Commercial	$33.14
Rate for Payer: UnitedHealthcare Commercial	$36.81
Rate for Payer: WPPA Medicare Advantage	$1,200.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

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