|
Clavicle Strap Adult X-Large
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
3250275
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$19.80 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.90
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Clavicle Strap Small
|
Facility
|
OP
|
$33.00
|
|
| Hospital Charge Code |
3250309
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Aetna Commercial |
$29.70
|
| Rate for Payer: Humana Medicare Advantage |
$13.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$31.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.20
|
| Rate for Payer: WPPA Medicare Advantage |
$19.80
|
|
|
Clavicle Strap Small
|
Facility
|
IP
|
$33.00
|
|
| Hospital Charge Code |
3250309
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$29.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$31.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Clavicle Strap XS/Child
|
Facility
|
OP
|
$33.00
|
|
| Hospital Charge Code |
3257116
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Aetna Commercial |
$29.70
|
| Rate for Payer: Humana Medicare Advantage |
$13.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$31.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.20
|
| Rate for Payer: WPPA Medicare Advantage |
$19.80
|
|
|
Clavicle Strap XS/Child
|
Facility
|
IP
|
$33.00
|
|
| Hospital Charge Code |
3257116
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$29.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$31.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Clavicle Strap Youth Medium
|
Facility
|
OP
|
$33.00
|
|
| Hospital Charge Code |
3250291
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$31.35 |
| Rate for Payer: Aetna Commercial |
$29.70
|
| Rate for Payer: Humana Medicare Advantage |
$13.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$31.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.20
|
| Rate for Payer: WPPA Medicare Advantage |
$19.80
|
|
|
Clavicle Strap Youth Medium
|
Facility
|
IP
|
$33.00
|
|
| Hospital Charge Code |
3250291
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$29.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$29.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$31.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
clindamycin 150 mg Cap [HMC]
|
Facility
|
IP
|
$8.45
|
|
|
Service Code
|
NDC 51079059820
|
| Hospital Charge Code |
3809039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.61 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.61
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.03
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
clindamycin 150 mg Cap [HMC]
|
Facility
|
IP
|
$5.52
|
|
|
Service Code
|
NDC 00009022502
|
| Hospital Charge Code |
3809039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.24
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
clindamycin 150 mg Cap [HMC]
|
Facility
|
OP
|
$5.52
|
|
|
Service Code
|
NDC 00009022502
|
| Hospital Charge Code |
3809039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$5.24 |
| Rate for Payer: Aetna Commercial |
$4.97
|
| Rate for Payer: Humana Medicare Advantage |
$2.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.21
|
| Rate for Payer: WPPA Medicare Advantage |
$3.31
|
|
|
clindamycin 150 mg Cap [HMC]
|
Facility
|
OP
|
$8.45
|
|
|
Service Code
|
NDC 51079059820
|
| Hospital Charge Code |
3809039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$8.03 |
| Rate for Payer: Aetna Commercial |
$7.61
|
| Rate for Payer: Humana Medicare Advantage |
$3.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.38
|
| Rate for Payer: WPPA Medicare Advantage |
$5.07
|
|
|
clindamycin 150 mg Cap [HMC]
|
Facility
|
IP
|
$7.19
|
|
|
Service Code
|
NDC 00904595961
|
| Hospital Charge Code |
3809039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.47
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.83
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
clindamycin 150 mg Cap [HMC]
|
Facility
|
OP
|
$7.19
|
|
|
Service Code
|
NDC 00904595961
|
| Hospital Charge Code |
3809039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$6.83 |
| Rate for Payer: Aetna Commercial |
$6.47
|
| Rate for Payer: Humana Medicare Advantage |
$3.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.88
|
| Rate for Payer: WPPA Medicare Advantage |
$4.31
|
|
|
clindamycin 150 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$37.66
|
|
|
Service Code
|
NDC 00009060225
|
| Hospital Charge Code |
3808416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.06 |
| Max. Negotiated Rate |
$35.78 |
| Rate for Payer: Aetna Commercial |
$33.89
|
| Rate for Payer: Humana Medicare Advantage |
$15.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.06
|
| Rate for Payer: WPPA Medicare Advantage |
$22.60
|
|
|
clindamycin 150 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$37.66
|
|
|
Service Code
|
NDC 00009077526
|
| Hospital Charge Code |
3808416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.06 |
| Max. Negotiated Rate |
$35.78 |
| Rate for Payer: Aetna Commercial |
$33.89
|
| Rate for Payer: Humana Medicare Advantage |
$15.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.06
|
| Rate for Payer: WPPA Medicare Advantage |
$22.60
|
|
|
clindamycin 150 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$37.66
|
|
|
Service Code
|
NDC 00009407304
|
| Hospital Charge Code |
3808416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.06 |
| Max. Negotiated Rate |
$35.78 |
| Rate for Payer: Aetna Commercial |
$33.89
|
| Rate for Payer: Humana Medicare Advantage |
$15.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.06
|
| Rate for Payer: WPPA Medicare Advantage |
$22.60
|
|
|
clindamycin 150 mg/mL IV Sol [HMC]
|
Facility
|
IP
|
$37.66
|
|
|
Service Code
|
NDC 00009407304
|
| Hospital Charge Code |
3808416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.89 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$33.89
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.78
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
clindamycin 150 mg/mL IV Sol [HMC]
|
Facility
|
IP
|
$37.66
|
|
|
Service Code
|
NDC 00009077526
|
| Hospital Charge Code |
3808416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.89 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$33.89
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.78
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
clindamycin 150 mg/mL IV Sol [HMC]
|
Facility
|
IP
|
$37.66
|
|
|
Service Code
|
NDC 00009060225
|
| Hospital Charge Code |
3808416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.89 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$33.89
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.78
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
clindamycin 300 mg Cap
|
Facility
|
OP
|
$8.92
|
|
|
Service Code
|
NDC 00904719461
|
| Hospital Charge Code |
3808441
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$8.47 |
| Rate for Payer: Aetna Commercial |
$8.03
|
| Rate for Payer: Humana Medicare Advantage |
$3.75
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.57
|
| Rate for Payer: WPPA Medicare Advantage |
$5.35
|
|
|
clindamycin 300 mg Cap
|
Facility
|
IP
|
$8.92
|
|
|
Service Code
|
NDC 00904719461
|
| Hospital Charge Code |
3808441
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.03 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.03
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.47
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
clindamycin 300 mg Cap [HMC]
|
Facility
|
IP
|
$16.15
|
|
|
Service Code
|
NDC 65862018601
|
| Hospital Charge Code |
3808441
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.54 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$14.54
|
| Rate for Payer: UnitedHealthcare Commercial |
$15.34
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
clindamycin 300 mg Cap [HMC]
|
Facility
|
OP
|
$8.89
|
|
|
Service Code
|
NDC 68084024401
|
| Hospital Charge Code |
3808441
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: Aetna Commercial |
$8.00
|
| Rate for Payer: Humana Medicare Advantage |
$3.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.56
|
| Rate for Payer: WPPA Medicare Advantage |
$5.33
|
|
|
clindamycin 300 mg Cap [HMC]
|
Facility
|
IP
|
$8.89
|
|
|
Service Code
|
NDC 68084024401
|
| Hospital Charge Code |
3808441
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.45
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
clindamycin 300 mg Cap [HMC]
|
Facility
|
OP
|
$16.15
|
|
|
Service Code
|
NDC 65862018601
|
| Hospital Charge Code |
3808441
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$6.46 |
| Max. Negotiated Rate |
$15.34 |
| Rate for Payer: Aetna Commercial |
$14.54
|
| Rate for Payer: Humana Medicare Advantage |
$6.78
|
| Rate for Payer: UnitedHealthcare Commercial |
$15.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.46
|
| Rate for Payer: WPPA Medicare Advantage |
$9.69
|
|
