|
azaTHIOprine 50 mg Tab [HMC]
|
Facility
|
IP
|
$7.54
|
|
|
Service Code
|
HCPCS J7500
|
| Hospital Charge Code |
3804503
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.79 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.79
|
| Rate for Payer: Aetna Commercial |
$10.20
|
| Rate for Payer: Aetna Commercial |
$8.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.76
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
azelastine Nasal 137 mcg/inh Spry [HMC]
|
Facility
|
IP
|
$162.07
|
|
|
Service Code
|
NDC 59651021430
|
| Hospital Charge Code |
3803752
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$145.86 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$145.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$153.97
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
azelastine Nasal 137 mcg/inh Spry [HMC]
|
Facility
|
OP
|
$162.07
|
|
|
Service Code
|
NDC 60505083305
|
| Hospital Charge Code |
3803752
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.83 |
| Max. Negotiated Rate |
$153.97 |
| Rate for Payer: Aetna Commercial |
$145.86
|
| Rate for Payer: Humana Medicare Advantage |
$68.07
|
| Rate for Payer: UnitedHealthcare Commercial |
$153.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.83
|
| Rate for Payer: WPPA Medicare Advantage |
$97.24
|
|
|
azelastine Nasal 137 mcg/inh Spry [HMC]
|
Facility
|
IP
|
$162.07
|
|
|
Service Code
|
NDC 60505083305
|
| Hospital Charge Code |
3803752
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$145.86 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$145.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$153.97
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
azelastine Nasal 137 mcg/inh Spry [HMC]
|
Facility
|
OP
|
$162.07
|
|
|
Service Code
|
NDC 59651021430
|
| Hospital Charge Code |
3803752
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.83 |
| Max. Negotiated Rate |
$153.97 |
| Rate for Payer: Aetna Commercial |
$145.86
|
| Rate for Payer: Humana Medicare Advantage |
$68.07
|
| Rate for Payer: UnitedHealthcare Commercial |
$153.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.83
|
| Rate for Payer: WPPA Medicare Advantage |
$97.24
|
|
|
azithromycin 250 mg Tab [HMC]
|
Facility
|
IP
|
$24.46
|
|
|
Service Code
|
NDC 00781808931
|
| Hospital Charge Code |
3809230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.01 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$22.01
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.24
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
azithromycin 250 mg Tab [HMC]
|
Facility
|
OP
|
$24.44
|
|
|
Service Code
|
NDC 51224002230
|
| Hospital Charge Code |
3809230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.78 |
| Max. Negotiated Rate |
$23.22 |
| Rate for Payer: Aetna Commercial |
$22.00
|
| Rate for Payer: Humana Medicare Advantage |
$10.26
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.78
|
| Rate for Payer: WPPA Medicare Advantage |
$14.66
|
|
|
azithromycin 250 mg Tab [HMC]
|
Facility
|
IP
|
$24.44
|
|
|
Service Code
|
NDC 51224002230
|
| Hospital Charge Code |
3809230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$22.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.22
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
azithromycin 250 mg Tab [HMC]
|
Facility
|
OP
|
$12.55
|
|
|
Service Code
|
NDC 00904670861
|
| Hospital Charge Code |
3809230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.02 |
| Max. Negotiated Rate |
$11.92 |
| Rate for Payer: Aetna Commercial |
$11.29
|
| Rate for Payer: Humana Medicare Advantage |
$5.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.02
|
| Rate for Payer: WPPA Medicare Advantage |
$7.53
|
|
|
azithromycin 250 mg Tab [HMC]
|
Facility
|
IP
|
$9.45
|
|
|
Service Code
|
NDC 50268007415
|
| Hospital Charge Code |
3809230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.51
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.98
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
azithromycin 250 mg Tab [HMC]
|
Facility
|
OP
|
$9.45
|
|
|
Service Code
|
NDC 00904735006
|
| Hospital Charge Code |
3809230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.78 |
| Max. Negotiated Rate |
$8.98 |
| Rate for Payer: Aetna Commercial |
$8.51
|
| Rate for Payer: Humana Medicare Advantage |
$3.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.78
|
| Rate for Payer: WPPA Medicare Advantage |
$5.67
|
|
|
azithromycin 250 mg Tab [HMC]
|
Facility
|
IP
|
$12.55
|
|
|
Service Code
|
NDC 00904670861
|
| Hospital Charge Code |
3809230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.29 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$11.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.92
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
azithromycin 250 mg Tab [HMC]
|
Facility
|
OP
|
$9.45
|
|
|
Service Code
|
NDC 50268007415
|
| Hospital Charge Code |
3809230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.78 |
| Max. Negotiated Rate |
$8.98 |
| Rate for Payer: Aetna Commercial |
$8.51
|
| Rate for Payer: Humana Medicare Advantage |
$3.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.78
|
| Rate for Payer: WPPA Medicare Advantage |
$5.67
|
|
|
azithromycin 250 mg Tab [HMC]
|
Facility
|
IP
|
$9.45
|
|
|
Service Code
|
NDC 00904735006
|
| Hospital Charge Code |
3809230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.51
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.98
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
azithromycin 250 mg Tab [HMC]
|
Facility
|
OP
|
$24.46
|
|
|
Service Code
|
NDC 00781808931
|
| Hospital Charge Code |
3809230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.78 |
| Max. Negotiated Rate |
$23.24 |
| Rate for Payer: Aetna Commercial |
$22.01
|
| Rate for Payer: Humana Medicare Advantage |
$10.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.78
|
| Rate for Payer: WPPA Medicare Advantage |
$14.68
|
|
|
azithromycin 500 mg IV Inj [HMC]
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
3802234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$30.60
|
| Rate for Payer: Aetna Commercial |
$38.70
|
| Rate for Payer: Aetna Commercial |
$55.71
|
| Rate for Payer: Aetna Commercial |
$29.30
|
| Rate for Payer: Aetna Commercial |
$32.27
|
| Rate for Payer: Aetna Commercial |
$34.92
|
| Rate for Payer: Aetna Commercial |
$35.31
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.06
|
| Rate for Payer: UnitedHealthcare Commercial |
$58.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$32.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.93
|
| Rate for Payer: UnitedHealthcare Commercial |
$40.85
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
azithromycin 500 mg IV Inj [HMC]
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
3802234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$40.85 |
| Rate for Payer: Aetna Commercial |
$38.70
|
| Rate for Payer: Aetna Commercial |
$34.92
|
| Rate for Payer: Aetna Commercial |
$35.31
|
| Rate for Payer: Aetna Commercial |
$55.71
|
| Rate for Payer: Aetna Commercial |
$29.30
|
| Rate for Payer: Aetna Commercial |
$30.60
|
| Rate for Payer: Aetna Commercial |
$32.27
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$3.64
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$3.64
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$3.64
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$3.64
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$3.64
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$3.64
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$3.64
|
| Rate for Payer: Humana Medicare Advantage |
$15.06
|
| Rate for Payer: Humana Medicare Advantage |
$16.30
|
| Rate for Payer: Humana Medicare Advantage |
$16.48
|
| Rate for Payer: Humana Medicare Advantage |
$26.00
|
| Rate for Payer: Humana Medicare Advantage |
$18.06
|
| Rate for Payer: Humana Medicare Advantage |
$13.68
|
| Rate for Payer: Humana Medicare Advantage |
$14.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$40.85
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.93
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.06
|
| Rate for Payer: UnitedHealthcare Commercial |
$32.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$58.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.04
|
| Rate for Payer: WPPA Medicare Advantage |
$20.40
|
| Rate for Payer: WPPA Medicare Advantage |
$37.14
|
| Rate for Payer: WPPA Medicare Advantage |
$21.51
|
| Rate for Payer: WPPA Medicare Advantage |
$25.80
|
| Rate for Payer: WPPA Medicare Advantage |
$23.28
|
| Rate for Payer: WPPA Medicare Advantage |
$19.54
|
| Rate for Payer: WPPA Medicare Advantage |
$23.54
|
|
|
aztreonam 2 g Inj [HMC]
|
Facility
|
IP
|
$151.96
|
|
|
Service Code
|
NDC 63323040220
|
| Hospital Charge Code |
3802210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$136.76 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$136.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$144.36
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
aztreonam 2 g Inj [HMC]
|
Facility
|
OP
|
$151.96
|
|
|
Service Code
|
NDC 63323040220
|
| Hospital Charge Code |
3802210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.78 |
| Max. Negotiated Rate |
$144.36 |
| Rate for Payer: Aetna Commercial |
$136.76
|
| Rate for Payer: Humana Medicare Advantage |
$63.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$144.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$60.78
|
| Rate for Payer: WPPA Medicare Advantage |
$91.18
|
|
|
bacitracin/neomycin/polymyxin B Top Oint [HMC]
|
Facility
|
OP
|
$29.22
|
|
|
Service Code
|
NDC 00168001235
|
| Hospital Charge Code |
3807498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.69 |
| Max. Negotiated Rate |
$27.76 |
| Rate for Payer: Aetna Commercial |
$26.30
|
| Rate for Payer: Humana Medicare Advantage |
$12.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$27.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.69
|
| Rate for Payer: WPPA Medicare Advantage |
$17.53
|
|
|
bacitracin/neomycin/polymyxin B Top Oint [HMC]
|
Facility
|
IP
|
$28.33
|
|
|
Service Code
|
NDC 45802014370
|
| Hospital Charge Code |
3807498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.91
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bacitracin/neomycin/polymyxin B Top Oint [HMC]
|
Facility
|
IP
|
$24.74
|
|
|
Service Code
|
NDC 00904880567
|
| Hospital Charge Code |
3807498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.27 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.50
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bacitracin/neomycin/polymyxin B Top Oint [HMC]
|
Facility
|
IP
|
$26.59
|
|
|
Service Code
|
NDC 45802014303
|
| Hospital Charge Code |
3807498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.93 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$23.93
|
| Rate for Payer: UnitedHealthcare Commercial |
$25.26
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bacitracin/neomycin/polymyxin B Top Oint [HMC]
|
Facility
|
IP
|
$29.22
|
|
|
Service Code
|
NDC 00168001235
|
| Hospital Charge Code |
3807498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.30 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$26.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$27.76
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bacitracin/neomycin/polymyxin B Top Oint [HMC]
|
Facility
|
OP
|
$24.74
|
|
|
Service Code
|
NDC 00904880567
|
| Hospital Charge Code |
3807498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$23.50 |
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: Humana Medicare Advantage |
$10.39
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.90
|
| Rate for Payer: WPPA Medicare Advantage |
$14.84
|
|
