|
norEPINEPHrine 1 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$54.60
|
|
|
Service Code
|
NDC 00143931810
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$51.87 |
| Rate for Payer: Aetna Commercial |
$49.14
|
| Rate for Payer: Humana Medicare Advantage |
$22.93
|
| Rate for Payer: UnitedHealthcare Commercial |
$51.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$21.84
|
| Rate for Payer: WPPA Medicare Advantage |
$32.76
|
|
|
Norepinephrine, P QST
|
Facility
|
OP
|
$256.00
|
|
|
Service Code
|
HCPCS 82542
|
| Hospital Charge Code |
3557562
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$243.20 |
| Rate for Payer: Aetna Commercial |
$230.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$194.29
|
| Rate for Payer: Humana Medicare Advantage |
$107.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$243.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.48
|
| Rate for Payer: WPPA Medicare Advantage |
$153.60
|
|
|
Norepinephrine, P QST
|
Facility
|
IP
|
$256.00
|
|
|
Service Code
|
HCPCS 82542
|
| Hospital Charge Code |
3557562
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$230.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$230.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$243.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
NORMAL NEWBORN
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
MSDRG 795
|
| Min. Negotiated Rate |
$794.25 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: UnitedHealthcare Medicaid |
$794.25
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nortriptyline 10 mg Cap [HMC]
|
Facility
|
IP
|
$7.20
|
|
|
Service Code
|
NDC 51672400101
|
| Hospital Charge Code |
3800824
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.48 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.48
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.84
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nortriptyline 10 mg Cap [HMC]
|
Facility
|
OP
|
$6.32
|
|
|
Service Code
|
NDC 68084003101
|
| Hospital Charge Code |
3800824
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$6.00 |
| Rate for Payer: Aetna Commercial |
$5.69
|
| Rate for Payer: Humana Medicare Advantage |
$2.65
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.53
|
| Rate for Payer: WPPA Medicare Advantage |
$3.79
|
|
|
nortriptyline 10 mg Cap [HMC]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
NDC 51672400101
|
| Hospital Charge Code |
3800824
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$6.84 |
| Rate for Payer: Aetna Commercial |
$6.48
|
| Rate for Payer: Humana Medicare Advantage |
$3.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.88
|
| Rate for Payer: WPPA Medicare Advantage |
$4.32
|
|
|
nortriptyline 10 mg Cap [HMC]
|
Facility
|
IP
|
$6.32
|
|
|
Service Code
|
NDC 68084003101
|
| Hospital Charge Code |
3800824
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.69 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.69
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nortriptyline 25 mg Cap [HMC]
|
Facility
|
OP
|
$7.65
|
|
|
Service Code
|
NDC 68084003201
|
| Hospital Charge Code |
3808133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$7.27 |
| Rate for Payer: Aetna Commercial |
$6.88
|
| Rate for Payer: Humana Medicare Advantage |
$3.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.06
|
| Rate for Payer: WPPA Medicare Advantage |
$4.59
|
|
|
nortriptyline 25 mg Cap [HMC]
|
Facility
|
OP
|
$5.52
|
|
|
Service Code
|
NDC 51672400205
|
| Hospital Charge Code |
3808133
|
|
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
|
|
|
nortriptyline 25 mg Cap [HMC]
|
Facility
|
IP
|
$5.52
|
|
|
Service Code
|
NDC 51672400205
|
| Hospital Charge Code |
3808133
|
|
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
|
|
|
nortriptyline 25 mg Cap [HMC]
|
Facility
|
IP
|
$9.40
|
|
|
Service Code
|
NDC 00093081101
|
| Hospital Charge Code |
3808133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.93
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nortriptyline 25 mg Cap [HMC]
|
Facility
|
IP
|
$6.77
|
|
|
Service Code
|
NDC 50268060415
|
| Hospital Charge Code |
3808133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.09 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.43
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nortriptyline 25 mg Cap [HMC]
|
Facility
|
IP
|
$7.65
|
|
|
Service Code
|
NDC 68084003201
|
| Hospital Charge Code |
3808133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.88 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.27
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nortriptyline 25 mg Cap [HMC]
|
Facility
|
OP
|
$9.40
|
|
|
Service Code
|
NDC 00093081101
|
| Hospital Charge Code |
3808133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.76 |
| Max. Negotiated Rate |
$8.93 |
| Rate for Payer: Aetna Commercial |
$8.46
|
| Rate for Payer: Humana Medicare Advantage |
$3.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.76
|
| Rate for Payer: WPPA Medicare Advantage |
$5.64
|
|
|
nortriptyline 25 mg Cap [HMC]
|
Facility
|
OP
|
$6.77
|
|
|
Service Code
|
NDC 50268060415
|
| Hospital Charge Code |
3808133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Aetna Commercial |
$6.09
|
| Rate for Payer: Humana Medicare Advantage |
$2.84
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.71
|
| Rate for Payer: WPPA Medicare Advantage |
$4.06
|
|
|
nystatin 100,000 units/mL Oral Susp 473 mL [HMC]
|
Facility
|
OP
|
$61.42
|
|
|
Service Code
|
NDC 69315050447
|
| Hospital Charge Code |
3800586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.57 |
| Max. Negotiated Rate |
$58.35 |
| Rate for Payer: Aetna Commercial |
$55.28
|
| Rate for Payer: Humana Medicare Advantage |
$25.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$58.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.57
|
| Rate for Payer: WPPA Medicare Advantage |
$36.85
|
|
|
nystatin 100,000 units/mL Oral Susp 473 mL [HMC]
|
Facility
|
OP
|
$71.96
|
|
|
Service Code
|
NDC 66689000816
|
| Hospital Charge Code |
3800586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.78 |
| Max. Negotiated Rate |
$68.36 |
| Rate for Payer: Aetna Commercial |
$64.76
|
| Rate for Payer: Humana Medicare Advantage |
$30.22
|
| Rate for Payer: UnitedHealthcare Commercial |
$68.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.78
|
| Rate for Payer: WPPA Medicare Advantage |
$43.18
|
|
|
nystatin 100,000 units/mL Oral Susp 473 mL [HMC]
|
Facility
|
IP
|
$71.96
|
|
|
Service Code
|
NDC 66689000816
|
| Hospital Charge Code |
3800586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.76 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$64.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$68.36
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin 100,000 units/mL Oral Susp 473 mL [HMC]
|
Facility
|
IP
|
$61.42
|
|
|
Service Code
|
NDC 69315050447
|
| Hospital Charge Code |
3800586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.28 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$55.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$58.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin 100,000 units/mL Oral Susp 5 mL [HMC]
|
Facility
|
IP
|
$12.45
|
|
|
Service Code
|
NDC 00904727692
|
| Hospital Charge Code |
3806482
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$11.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.83
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin 100,000 units/mL Oral Susp 5 mL [HMC]
|
Facility
|
IP
|
$13.39
|
|
|
Service Code
|
NDC 68094059962
|
| Hospital Charge Code |
3806482
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$12.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.72
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin 100,000 units/mL Oral Susp 5 mL [HMC]
|
Facility
|
OP
|
$13.84
|
|
|
Service Code
|
NDC 00904727670
|
| Hospital Charge Code |
3806482
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$13.15 |
| Rate for Payer: Aetna Commercial |
$12.46
|
| Rate for Payer: Humana Medicare Advantage |
$5.81
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.54
|
| Rate for Payer: WPPA Medicare Advantage |
$8.30
|
|
|
nystatin 100,000 units/mL Oral Susp 5 mL [HMC]
|
Facility
|
IP
|
$13.84
|
|
|
Service Code
|
NDC 00904727670
|
| Hospital Charge Code |
3806482
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.46 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$12.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.15
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nystatin 100,000 units/mL Oral Susp 5 mL [HMC]
|
Facility
|
OP
|
$12.45
|
|
|
Service Code
|
NDC 00904727692
|
| Hospital Charge Code |
3806482
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.98 |
| Max. Negotiated Rate |
$11.83 |
| Rate for Payer: Aetna Commercial |
$11.21
|
| Rate for Payer: Humana Medicare Advantage |
$5.23
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.98
|
| Rate for Payer: WPPA Medicare Advantage |
$7.47
|
|
