|
amLODIPine 5 mg Tab [HMC]
|
Facility
|
OP
|
$9.93
|
|
|
Service Code
|
NDC 00904637061
|
| Hospital Charge Code |
3809370
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.97 |
| Max. Negotiated Rate |
$9.43 |
| Rate for Payer: Aetna Commercial |
$8.94
|
| Rate for Payer: Humana Medicare Advantage |
$4.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.97
|
| Rate for Payer: WPPA Medicare Advantage |
$5.96
|
|
|
Ammonia Level
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
HCPCS 82140
|
| Hospital Charge Code |
3551120
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$172.90 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$49.38
|
| Rate for Payer: Humana Medicare Advantage |
$76.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$172.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.38
|
| Rate for Payer: WPPA Medicare Advantage |
$109.20
|
|
|
Ammonia Level
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS 82140
|
| Hospital Charge Code |
3551120
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$163.80 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$172.90
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ammonium lactate Top 12% Lotion [HMC]
|
Facility
|
IP
|
$77.36
|
|
|
Service Code
|
NDC 00904598463
|
| Hospital Charge Code |
3800735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.62 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$69.62
|
| Rate for Payer: UnitedHealthcare Commercial |
$73.49
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ammonium lactate Top 12% Lotion [HMC]
|
Facility
|
OP
|
$77.36
|
|
|
Service Code
|
NDC 00904598463
|
| Hospital Charge Code |
3800735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.94 |
| Max. Negotiated Rate |
$73.49 |
| Rate for Payer: Aetna Commercial |
$69.62
|
| Rate for Payer: Humana Medicare Advantage |
$32.49
|
| Rate for Payer: UnitedHealthcare Commercial |
$73.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.94
|
| Rate for Payer: WPPA Medicare Advantage |
$46.42
|
|
|
Amnicot Finger Cot with Membrane Rupture Hook
|
Facility
|
IP
|
$16.00
|
|
| Hospital Charge Code |
3250277
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$14.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$15.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Amnicot Finger Cot with Membrane Rupture Hook
|
Facility
|
OP
|
$16.00
|
|
| Hospital Charge Code |
3250277
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.40 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Aetna Commercial |
$14.40
|
| Rate for Payer: Humana Medicare Advantage |
$6.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$15.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.40
|
| Rate for Payer: WPPA Medicare Advantage |
$9.60
|
|
|
Amnihook
|
Facility
|
IP
|
$2.70
|
|
| Hospital Charge Code |
3250276
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$2.43
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.56
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Amnihook
|
Facility
|
OP
|
$2.70
|
|
| Hospital Charge Code |
3250276
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna Commercial |
$2.43
|
| Rate for Payer: Humana Medicare Advantage |
$1.13
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.08
|
| Rate for Payer: WPPA Medicare Advantage |
$1.62
|
|
|
amoxicillin 250 mg Cap [HMC]
|
Facility
|
IP
|
$5.75
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
3800189
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.17 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.46
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
amoxicillin 250 mg Cap [HMC]
|
Facility
|
IP
|
$5.79
|
|
|
Service Code
|
NDC 00093310793
|
| Hospital Charge Code |
3800189
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.21 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.50
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
amoxicillin 250 mg Cap [HMC]
|
Facility
|
OP
|
$5.79
|
|
|
Service Code
|
NDC 00093310793
|
| Hospital Charge Code |
3800189
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$5.50 |
| Rate for Payer: Aetna Commercial |
$5.21
|
| Rate for Payer: Humana Medicare Advantage |
$2.43
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.32
|
| Rate for Payer: WPPA Medicare Advantage |
$3.47
|
|
|
amoxicillin 250 mg Cap [HMC]
|
Facility
|
OP
|
$5.75
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
3800189
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$5.46 |
| Rate for Payer: Aetna Commercial |
$5.17
|
| Rate for Payer: Humana Medicare Advantage |
$2.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.30
|
| Rate for Payer: WPPA Medicare Advantage |
$3.45
|
|
|
amoxicillin-clavulanate 400 mg-57 mg/5 mL Oral Liq 50 mL [HMC]
|
Facility
|
IP
|
$67.45
|
|
|
Service Code
|
NDC 65862053450
|
| Hospital Charge Code |
3809502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$60.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$64.08
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
amoxicillin-clavulanate 400 mg-57 mg/5 mL Oral Liq 50 mL [HMC]
|
Facility
|
OP
|
$67.45
|
|
|
Service Code
|
NDC 65862053450
|
| Hospital Charge Code |
3809502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.98 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna Commercial |
$60.70
|
| Rate for Payer: Humana Medicare Advantage |
$28.33
|
| Rate for Payer: UnitedHealthcare Commercial |
$64.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.98
|
| Rate for Payer: WPPA Medicare Advantage |
$40.47
|
|
|
amoxicillin-clavulanate 400 mg-57 mg/5 mL Oral Liq 50 mL [HMC]
|
Facility
|
OP
|
$67.45
|
|
|
Service Code
|
NDC 66685101200
|
| Hospital Charge Code |
3809502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.98 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna Commercial |
$60.70
|
| Rate for Payer: Humana Medicare Advantage |
$28.33
|
| Rate for Payer: UnitedHealthcare Commercial |
$64.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.98
|
| Rate for Payer: WPPA Medicare Advantage |
$40.47
|
|
|
amoxicillin-clavulanate 400 mg-57 mg/5 mL Oral Liq 50 mL [HMC]
|
Facility
|
IP
|
$67.45
|
|
|
Service Code
|
NDC 66685101200
|
| Hospital Charge Code |
3809502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$60.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$64.08
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab [HMC]
|
Facility
|
IP
|
$17.63
|
|
|
Service Code
|
NDC 00093227534
|
| Hospital Charge Code |
3800808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.87 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$15.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.75
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab [HMC]
|
Facility
|
IP
|
$17.63
|
|
|
Service Code
|
NDC 66685100100
|
| Hospital Charge Code |
3800808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.87 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$15.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.75
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab [HMC]
|
Facility
|
OP
|
$17.63
|
|
|
Service Code
|
NDC 66685100100
|
| Hospital Charge Code |
3800808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.05 |
| Max. Negotiated Rate |
$16.75 |
| Rate for Payer: Aetna Commercial |
$15.87
|
| Rate for Payer: Humana Medicare Advantage |
$7.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.05
|
| Rate for Payer: WPPA Medicare Advantage |
$10.58
|
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab [HMC]
|
Facility
|
OP
|
$17.63
|
|
|
Service Code
|
NDC 00781185220
|
| Hospital Charge Code |
3800808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.05 |
| Max. Negotiated Rate |
$16.75 |
| Rate for Payer: Aetna Commercial |
$15.87
|
| Rate for Payer: Humana Medicare Advantage |
$7.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.05
|
| Rate for Payer: WPPA Medicare Advantage |
$10.58
|
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab [HMC]
|
Facility
|
OP
|
$17.63
|
|
|
Service Code
|
NDC 00093227534
|
| Hospital Charge Code |
3800808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.05 |
| Max. Negotiated Rate |
$16.75 |
| Rate for Payer: Aetna Commercial |
$15.87
|
| Rate for Payer: Humana Medicare Advantage |
$7.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.05
|
| Rate for Payer: WPPA Medicare Advantage |
$10.58
|
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab [HMC]
|
Facility
|
OP
|
$19.85
|
|
|
Service Code
|
NDC 65862050301
|
| Hospital Charge Code |
3800808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.94 |
| Max. Negotiated Rate |
$18.86 |
| Rate for Payer: Aetna Commercial |
$17.86
|
| Rate for Payer: Humana Medicare Advantage |
$8.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.94
|
| Rate for Payer: WPPA Medicare Advantage |
$11.91
|
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab [HMC]
|
Facility
|
IP
|
$19.85
|
|
|
Service Code
|
NDC 65862050301
|
| Hospital Charge Code |
3800808
|
|
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 |
$18.86
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab [HMC]
|
Facility
|
IP
|
$17.63
|
|
|
Service Code
|
NDC 00781185220
|
| Hospital Charge Code |
3800808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.87 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$15.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.75
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
