Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

ocular lubricant Gel [HMC]

Facility

OP

$39.80

Service Code	NDC 00023455430
Hospital Charge Code	3800720
Hospital Revenue Code	250
Min. Negotiated Rate	$15.92
Max. Negotiated Rate	$37.81
Rate for Payer: Aetna Commercial	$35.82
Rate for Payer: Humana Medicare Advantage	$16.72
Rate for Payer: UnitedHealthcare Commercial	$37.81
Rate for Payer: UnitedHealthcare Medicaid	$15.92
Rate for Payer: WPPA Medicare Advantage	$23.88

ocular lubricant Oint [HMC]

Facility

OP

$45.65

Service Code	NDC 00023031204
Hospital Charge Code	3808836
Hospital Revenue Code	250
Min. Negotiated Rate	$18.26
Max. Negotiated Rate	$43.37
Rate for Payer: Aetna Commercial	$41.09
Rate for Payer: Humana Medicare Advantage	$19.17
Rate for Payer: UnitedHealthcare Commercial	$43.37
Rate for Payer: UnitedHealthcare Medicaid	$18.26
Rate for Payer: WPPA Medicare Advantage	$27.39

ocular lubricant Oint [HMC]

Facility

IP

$45.65

Service Code	NDC 00023031204
Hospital Charge Code	3808836
Hospital Revenue Code	250
Min. Negotiated Rate	$41.09
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.09
Rate for Payer: UnitedHealthcare Commercial	$43.37
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ocular lubricant preserved Sol [HMC]

Facility

OP

$26.92

Service Code	NDC 57896018105
Hospital Charge Code	3806939
Hospital Revenue Code	250
Min. Negotiated Rate	$10.77
Max. Negotiated Rate	$25.57
Rate for Payer: Aetna Commercial	$24.23
Rate for Payer: Humana Medicare Advantage	$11.31
Rate for Payer: UnitedHealthcare Commercial	$25.57
Rate for Payer: UnitedHealthcare Medicaid	$10.77
Rate for Payer: WPPA Medicare Advantage	$16.15

ocular lubricant preserved Sol [HMC]

Facility

OP

$35.10

Service Code	NDC 00023079815
Hospital Charge Code	3806939
Hospital Revenue Code	250
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$33.34
Rate for Payer: Aetna Commercial	$31.59
Rate for Payer: Humana Medicare Advantage	$14.74
Rate for Payer: UnitedHealthcare Commercial	$33.34
Rate for Payer: UnitedHealthcare Medicaid	$14.04
Rate for Payer: WPPA Medicare Advantage	$21.06

ocular lubricant preserved Sol [HMC]

Facility

IP

$35.10

Service Code	NDC 00023079815
Hospital Charge Code	3806939
Hospital Revenue Code	250
Min. Negotiated Rate	$31.59
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$31.59
Rate for Payer: UnitedHealthcare Commercial	$33.34
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ocular lubricant preserved Sol [HMC]

Facility

IP

$26.92

Service Code	NDC 57896018105
Hospital Charge Code	3806939
Hospital Revenue Code	250
Min. Negotiated Rate	$24.23
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.23
Rate for Payer: UnitedHealthcare Commercial	$25.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ocular lubricant preserved Sol [HMC]

Facility

OP

$23.48

Service Code	NDC 57896018405
Hospital Charge Code	3806939
Hospital Revenue Code	250
Min. Negotiated Rate	$9.39
Max. Negotiated Rate	$22.31
Rate for Payer: Aetna Commercial	$21.13
Rate for Payer: Humana Medicare Advantage	$9.86
Rate for Payer: UnitedHealthcare Commercial	$22.31
Rate for Payer: UnitedHealthcare Medicaid	$9.39
Rate for Payer: WPPA Medicare Advantage	$14.09

ocular lubricant preserved Sol [HMC]

Facility

OP

$27.58

Service Code	NDC 00904501735
Hospital Charge Code	3806939
Hospital Revenue Code	250
Min. Negotiated Rate	$11.03
Max. Negotiated Rate	$26.20
Rate for Payer: Aetna Commercial	$24.82
Rate for Payer: Humana Medicare Advantage	$11.58
Rate for Payer: UnitedHealthcare Commercial	$26.20
Rate for Payer: UnitedHealthcare Medicaid	$11.03
Rate for Payer: WPPA Medicare Advantage	$16.55

ocular lubricant preserved Sol [HMC]

Facility

IP

$23.48

Service Code	NDC 57896018405
Hospital Charge Code	3806939
Hospital Revenue Code	250
Min. Negotiated Rate	$21.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$21.13
Rate for Payer: UnitedHealthcare Commercial	$22.31
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ocular lubricant preserved Sol [HMC]

Facility

IP

$27.58

Service Code	NDC 00904501735
Hospital Charge Code	3806939
Hospital Revenue Code	250
Min. Negotiated Rate	$24.82
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.82
Rate for Payer: UnitedHealthcare Commercial	$26.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ocular lubricant Sol [HMC]

Facility

OP

$30.50

Service Code	NDC 70000050201
Hospital Charge Code	3806939
Hospital Revenue Code	250
Min. Negotiated Rate	$12.20
Max. Negotiated Rate	$28.98
Rate for Payer: Aetna Commercial	$27.45
Rate for Payer: Humana Medicare Advantage	$12.81
Rate for Payer: UnitedHealthcare Commercial	$28.98
Rate for Payer: UnitedHealthcare Medicaid	$12.20
Rate for Payer: WPPA Medicare Advantage	$18.30

ocular lubricant Sol [HMC]

Facility

IP

$30.50

Service Code	NDC 70000050201
Hospital Charge Code	3806939
Hospital Revenue Code	250
Min. Negotiated Rate	$27.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.45
Rate for Payer: UnitedHealthcare Commercial	$28.98
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ofloxacin ophthalmic 0.3% Sol [HMC]

Facility

OP

$48.27

Service Code	NDC 60505056000
Hospital Charge Code	3800712
Hospital Revenue Code	250
Min. Negotiated Rate	$19.31
Max. Negotiated Rate	$45.86
Rate for Payer: Aetna Commercial	$43.44
Rate for Payer: Humana Medicare Advantage	$20.27
Rate for Payer: UnitedHealthcare Commercial	$45.86
Rate for Payer: UnitedHealthcare Medicaid	$19.31
Rate for Payer: WPPA Medicare Advantage	$28.96

ofloxacin ophthalmic 0.3% Sol [HMC]

Facility

IP

$48.27

Service Code	NDC 17478071310
Hospital Charge Code	3800712
Hospital Revenue Code	250
Min. Negotiated Rate	$43.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$43.44
Rate for Payer: UnitedHealthcare Commercial	$45.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ofloxacin ophthalmic 0.3% Sol [HMC]

Facility

IP

$114.97

Service Code	NDC 70756060730
Hospital Charge Code	3800712
Hospital Revenue Code	250
Min. Negotiated Rate	$103.47
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$103.47
Rate for Payer: UnitedHealthcare Commercial	$109.22
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ofloxacin ophthalmic 0.3% Sol [HMC]

Facility

OP

$48.27

Service Code	NDC 17478071310
Hospital Charge Code	3800712
Hospital Revenue Code	250
Min. Negotiated Rate	$19.31
Max. Negotiated Rate	$45.86
Rate for Payer: Aetna Commercial	$43.44
Rate for Payer: Humana Medicare Advantage	$20.27
Rate for Payer: UnitedHealthcare Commercial	$45.86
Rate for Payer: UnitedHealthcare Medicaid	$19.31
Rate for Payer: WPPA Medicare Advantage	$28.96

ofloxacin ophthalmic 0.3% Sol [HMC]

Facility

IP

$48.27

Service Code	NDC 60505056000
Hospital Charge Code	3800712
Hospital Revenue Code	250
Min. Negotiated Rate	$43.44
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$43.44
Rate for Payer: UnitedHealthcare Commercial	$45.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ofloxacin ophthalmic 0.3% Sol [HMC]

Facility

OP

$114.97

Service Code	NDC 70756060730
Hospital Charge Code	3800712
Hospital Revenue Code	250
Min. Negotiated Rate	$45.99
Max. Negotiated Rate	$109.22
Rate for Payer: Aetna Commercial	$103.47
Rate for Payer: Humana Medicare Advantage	$48.29
Rate for Payer: UnitedHealthcare Commercial	$109.22
Rate for Payer: UnitedHealthcare Medicaid	$45.99
Rate for Payer: WPPA Medicare Advantage	$68.98

ofloxacin otic 0.3% Sol [HMC]

Facility

IP

$228.28

Service Code	NDC 60505036301
Hospital Charge Code	3800712
Hospital Revenue Code	250
Min. Negotiated Rate	$205.45
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$205.45
Rate for Payer: UnitedHealthcare Commercial	$216.87
Rate for Payer: WPPA Medicare Advantage	$1,200.00

ofloxacin otic 0.3% Sol [HMC]

Facility

OP

$228.28

Service Code	NDC 60505036301
Hospital Charge Code	3800712
Hospital Revenue Code	250
Min. Negotiated Rate	$91.31
Max. Negotiated Rate	$216.87
Rate for Payer: Aetna Commercial	$205.45
Rate for Payer: Humana Medicare Advantage	$95.88
Rate for Payer: UnitedHealthcare Commercial	$216.87
Rate for Payer: UnitedHealthcare Medicaid	$91.31
Rate for Payer: WPPA Medicare Advantage	$136.97

OLANZapine 5 mg Dis Tab [HMC]

Facility

OP

$33.00

Service Code	NDC 33342008307
Hospital Charge Code	3803408
Hospital Revenue Code	250
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

OLANZapine 5 mg Dis Tab [HMC]

Facility

IP

$33.00

Service Code	NDC 33342008307
Hospital Charge Code	3803408
Hospital Revenue Code	250
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

OLANZapine 5 mg Dis Tab [HMC]

Facility

IP

$11.23

Service Code	NDC 55111026281
Hospital Charge Code	3803408
Hospital Revenue Code	250
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$10.11
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: WPPA Medicare Advantage	$1,200.00

OLANZapine 5 mg Dis Tab [HMC]

Facility

OP

$11.23

Service Code	NDC 55111026281
Hospital Charge Code	3803408
Hospital Revenue Code	250
Min. Negotiated Rate	$4.49
Max. Negotiated Rate	$10.67
Rate for Payer: Aetna Commercial	$10.11
Rate for Payer: Humana Medicare Advantage	$4.72
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: UnitedHealthcare Medicaid	$4.49
Rate for Payer: WPPA Medicare Advantage	$6.74

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