|
chlorpheniramine-HYDROcodone 8 mg-10 mg/5 mL Oral Susp, ER 118 mL [HMC]
|
Facility
|
OP
|
$108.56
|
|
|
Service Code
|
NDC 62542030104
|
| Hospital Charge Code |
3807655
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.42 |
| Max. Negotiated Rate |
$103.13 |
| Rate for Payer: Aetna Commercial |
$97.70
|
| Rate for Payer: Humana Medicare Advantage |
$45.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$103.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.42
|
| Rate for Payer: WPPA Medicare Advantage |
$65.14
|
|
|
chlorpheniramine-HYDROcodone 8 mg-10 mg/5 mL Oral Susp, ER 118 mL [HMC]
|
Facility
|
IP
|
$108.56
|
|
|
Service Code
|
NDC 62542030104
|
| Hospital Charge Code |
3807655
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$97.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$103.13
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
chlorpheniramine-hydrocodone 8 mg-10 mg/5 mL Sus [HMC]
|
Facility
|
IP
|
$118.68
|
|
|
Service Code
|
NDC 27808008602
|
| Hospital Charge Code |
3807655
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.81 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$106.81
|
| Rate for Payer: UnitedHealthcare Commercial |
$112.75
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
chlorpheniramine-hydrocodone 8 mg-10 mg/5 mL Sus [HMC]
|
Facility
|
OP
|
$118.68
|
|
|
Service Code
|
NDC 27808008602
|
| Hospital Charge Code |
3807655
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.47 |
| Max. Negotiated Rate |
$112.75 |
| Rate for Payer: Aetna Commercial |
$106.81
|
| Rate for Payer: Humana Medicare Advantage |
$49.85
|
| Rate for Payer: UnitedHealthcare Commercial |
$112.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.47
|
| Rate for Payer: WPPA Medicare Advantage |
$71.21
|
|
|
chlorproMAZINE 25 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
3808058
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.77 |
| Max. Negotiated Rate |
$73.15 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$35.94
|
| Rate for Payer: Humana Medicare Advantage |
$32.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$73.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.77
|
| Rate for Payer: WPPA Medicare Advantage |
$46.20
|
|
|
chlorproMAZINE 25 mg/mL Inj Sol [HMC]
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
3808058
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.30 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$73.15
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
chlorproMAZINE 25 mg/mL Inj Sol [HMC]
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
NDC 55150031825
|
| Hospital Charge Code |
3808058
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.30 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$73.15
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
chlorproMAZINE 25 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
NDC 55150031825
|
| Hospital Charge Code |
3808058
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$73.15 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Humana Medicare Advantage |
$32.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$73.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.80
|
| Rate for Payer: WPPA Medicare Advantage |
$46.20
|
|
|
chlorproMAZINE 25 mg Tab [HMC]
|
Facility
|
IP
|
$23.71
|
|
|
Service Code
|
HCPCS Q0161
|
| Hospital Charge Code |
3804231
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.34 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$21.34
|
| Rate for Payer: Aetna Commercial |
$21.69
|
| Rate for Payer: UnitedHealthcare Commercial |
$22.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$22.89
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
chlorproMAZINE 25 mg Tab [HMC]
|
Facility
|
OP
|
$24.10
|
|
|
Service Code
|
HCPCS Q0161
|
| Hospital Charge Code |
3804231
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$22.89 |
| Rate for Payer: Aetna Commercial |
$21.69
|
| Rate for Payer: Aetna Commercial |
$21.34
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2.18
|
| Rate for Payer: Humana Medicare Advantage |
$9.96
|
| Rate for Payer: Humana Medicare Advantage |
$10.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$22.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$22.89
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.48
|
| Rate for Payer: WPPA Medicare Advantage |
$14.23
|
| Rate for Payer: WPPA Medicare Advantage |
$14.46
|
|
|
chlorthalidone 25 mg Tab [HMC]
|
Facility
|
IP
|
$8.62
|
|
|
Service Code
|
NDC 00378022201
|
| Hospital Charge Code |
3809776
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.76 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.19
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
chlorthalidone 25 mg Tab [HMC]
|
Facility
|
IP
|
$12.12
|
|
|
Service Code
|
NDC 00904690004
|
| Hospital Charge Code |
3809776
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.91 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.51
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
chlorthalidone 25 mg Tab [HMC]
|
Facility
|
OP
|
$11.89
|
|
|
Service Code
|
NDC 50268016715
|
| Hospital Charge Code |
3809776
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.76 |
| Max. Negotiated Rate |
$11.30 |
| Rate for Payer: Aetna Commercial |
$10.70
|
| Rate for Payer: Humana Medicare Advantage |
$4.99
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.76
|
| Rate for Payer: WPPA Medicare Advantage |
$7.13
|
|
|
chlorthalidone 25 mg Tab [HMC]
|
Facility
|
IP
|
$11.89
|
|
|
Service Code
|
NDC 50268016715
|
| Hospital Charge Code |
3809776
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.30
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
chlorthalidone 25 mg Tab [HMC]
|
Facility
|
OP
|
$8.62
|
|
|
Service Code
|
NDC 00378022201
|
| Hospital Charge Code |
3809776
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$8.19 |
| Rate for Payer: Aetna Commercial |
$7.76
|
| Rate for Payer: Humana Medicare Advantage |
$3.62
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.45
|
| Rate for Payer: WPPA Medicare Advantage |
$5.17
|
|
|
chlorthalidone 25 mg Tab [HMC]
|
Facility
|
OP
|
$12.12
|
|
|
Service Code
|
NDC 00904690004
|
| Hospital Charge Code |
3809776
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.85 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: Humana Medicare Advantage |
$5.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.85
|
| Rate for Payer: WPPA Medicare Advantage |
$7.27
|
|
|
Cholangiogram Catheter 4.5FR X 18 Taut
|
Facility
|
IP
|
$198.00
|
|
| Hospital Charge Code |
3258253
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$178.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$188.10
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Cholangiogram Catheter 4.5FR X 18 Taut
|
Facility
|
OP
|
$198.00
|
|
| Hospital Charge Code |
3258253
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$79.20 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: Humana Medicare Advantage |
$83.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$188.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$79.20
|
| Rate for Payer: WPPA Medicare Advantage |
$118.80
|
|
|
Cholangiogram Catheter 5 Fr x 65 cm with Wire Guide 0.021 x 90 cm, Set includes introducer sheath n
|
Facility
|
IP
|
$206.50
|
|
| Hospital Charge Code |
3258256
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$185.85 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$185.85
|
| Rate for Payer: UnitedHealthcare Commercial |
$196.18
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Cholangiogram Catheter 5 Fr x 65 cm with Wire Guide 0.021 x 90 cm, Set includes introducer sheath n
|
Facility
|
OP
|
$206.50
|
|
| Hospital Charge Code |
3258256
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$82.60 |
| Max. Negotiated Rate |
$196.18 |
| Rate for Payer: Aetna Commercial |
$185.85
|
| Rate for Payer: Humana Medicare Advantage |
$86.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$196.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$82.60
|
| Rate for Payer: WPPA Medicare Advantage |
$123.90
|
|
|
cholecalciferol 1000 intl units oral tablet [HMC]
|
Facility
|
IP
|
$5.09
|
|
|
Service Code
|
NDC 00904582460
|
| Hospital Charge Code |
3809505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.58
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.84
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
cholecalciferol 1000 intl units oral tablet [HMC]
|
Facility
|
OP
|
$5.09
|
|
|
Service Code
|
NDC 00904582460
|
| Hospital Charge Code |
3809505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna Commercial |
$4.58
|
| Rate for Payer: Humana Medicare Advantage |
$2.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.04
|
| Rate for Payer: WPPA Medicare Advantage |
$3.05
|
|
|
cholecalciferol 1000 intl units oral tablet [HMC]
|
Facility
|
IP
|
$5.30
|
|
|
Service Code
|
NDC 31604001870
|
| Hospital Charge Code |
3809505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.77 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.77
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.04
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
cholecalciferol 1000 intl units oral tablet [HMC]
|
Facility
|
OP
|
$5.30
|
|
|
Service Code
|
NDC 31604001870
|
| Hospital Charge Code |
3809505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Aetna Commercial |
$4.77
|
| 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 |
$3.18
|
|
|
cholecalciferol 1,000 IntlUnit Tab [HMC]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 96295012848
|
| Hospital Charge Code |
3809505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Humana Medicare Advantage |
$2.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.00
|
| Rate for Payer: WPPA Medicare Advantage |
$3.00
|
|
