|
petrolatum topical - Ointment 1.75 oz [HMC]
|
Facility
|
IP
|
$24.24
|
|
|
Service Code
|
NDC 00521231100
|
| Hospital Charge Code |
3268634
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$21.82 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$21.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.03
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
petrolatum topical - Ointment 1.75 oz [HMC]
|
Facility
|
OP
|
$24.24
|
|
|
Service Code
|
NDC 00521231100
|
| Hospital Charge Code |
3268634
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$9.70 |
| Max. Negotiated Rate |
$23.03 |
| Rate for Payer: Aetna Commercial |
$21.82
|
| Rate for Payer: Humana Medicare Advantage |
$10.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.70
|
| Rate for Payer: WPPA Medicare Advantage |
$14.54
|
|
|
phenazopyridine 100 mg Tab [HMC]
|
Facility
|
OP
|
$12.20
|
|
|
Service Code
|
NDC 75826011410
|
| Hospital Charge Code |
3806581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.88 |
| Max. Negotiated Rate |
$11.59 |
| Rate for Payer: Aetna Commercial |
$10.98
|
| Rate for Payer: Humana Medicare Advantage |
$5.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.88
|
| Rate for Payer: WPPA Medicare Advantage |
$7.32
|
|
|
phenazopyridine 100 mg Tab [HMC]
|
Facility
|
IP
|
$13.10
|
|
|
Service Code
|
NDC 65162068110
|
| Hospital Charge Code |
3806581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$11.79
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.45
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
phenazopyridine 100 mg Tab [HMC]
|
Facility
|
OP
|
$13.10
|
|
|
Service Code
|
NDC 65162068110
|
| Hospital Charge Code |
3806581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.24 |
| Max. Negotiated Rate |
$12.45 |
| Rate for Payer: Aetna Commercial |
$11.79
|
| Rate for Payer: Humana Medicare Advantage |
$5.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.24
|
| Rate for Payer: WPPA Medicare Advantage |
$7.86
|
|
|
phenazopyridine 100 mg Tab [HMC]
|
Facility
|
IP
|
$12.20
|
|
|
Service Code
|
NDC 75826011410
|
| Hospital Charge Code |
3806581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.59
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
phenazopyridine 100 mg Tab [HMC]
|
Facility
|
OP
|
$6.52
|
|
|
Service Code
|
NDC 68084029201
|
| Hospital Charge Code |
3806581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$6.19 |
| Rate for Payer: Aetna Commercial |
$5.87
|
| Rate for Payer: Humana Medicare Advantage |
$2.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.61
|
| Rate for Payer: WPPA Medicare Advantage |
$3.91
|
|
|
phenazopyridine 100 mg Tab [HMC]
|
Facility
|
IP
|
$13.10
|
|
|
Service Code
|
NDC 51293081001
|
| Hospital Charge Code |
3806581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$11.79
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.45
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
phenazopyridine 100 mg Tab [HMC]
|
Facility
|
OP
|
$13.10
|
|
|
Service Code
|
NDC 51293081001
|
| Hospital Charge Code |
3806581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.24 |
| Max. Negotiated Rate |
$12.45 |
| Rate for Payer: Aetna Commercial |
$11.79
|
| Rate for Payer: Humana Medicare Advantage |
$5.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.24
|
| Rate for Payer: WPPA Medicare Advantage |
$7.86
|
|
|
phenazopyridine 100 mg Tab [HMC]
|
Facility
|
IP
|
$6.52
|
|
|
Service Code
|
NDC 68084029201
|
| Hospital Charge Code |
3806581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.87 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.19
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
PHENobarbital 64.8 mg Tab [HMC]
|
Facility
|
IP
|
$5.56
|
|
|
Service Code
|
NDC 75826014110
|
| Hospital Charge Code |
3804029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.28
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
PHENobarbital 64.8 mg Tab [HMC]
|
Facility
|
OP
|
$7.51
|
|
|
Service Code
|
NDC 16571066701
|
| Hospital Charge Code |
3804029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$7.13 |
| Rate for Payer: Aetna Commercial |
$6.76
|
| Rate for Payer: Humana Medicare Advantage |
$3.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: WPPA Medicare Advantage |
$4.51
|
|
|
PHENobarbital 64.8 mg Tab [HMC]
|
Facility
|
OP
|
$5.56
|
|
|
Service Code
|
NDC 75826014110
|
| Hospital Charge Code |
3804029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$5.28 |
| Rate for Payer: Aetna Commercial |
$5.00
|
| Rate for Payer: Humana Medicare Advantage |
$2.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.22
|
| Rate for Payer: WPPA Medicare Advantage |
$3.34
|
|
|
PHENobarbital 64.8 mg Tab [HMC]
|
Facility
|
OP
|
$11.16
|
|
|
Service Code
|
NDC 68084098925
|
| Hospital Charge Code |
3804029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$10.60 |
| Rate for Payer: Aetna Commercial |
$10.04
|
| Rate for Payer: Humana Medicare Advantage |
$4.69
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.46
|
| Rate for Payer: WPPA Medicare Advantage |
$6.70
|
|
|
PHENobarbital 64.8 mg Tab [HMC]
|
Facility
|
IP
|
$7.53
|
|
|
Service Code
|
NDC 00603516721
|
| Hospital Charge Code |
3804029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.78 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.78
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.15
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
PHENobarbital 64.8 mg Tab [HMC]
|
Facility
|
IP
|
$11.16
|
|
|
Service Code
|
NDC 68084098925
|
| Hospital Charge Code |
3804029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.04
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.60
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
PHENobarbital 64.8 mg Tab [HMC]
|
Facility
|
IP
|
$7.51
|
|
|
Service Code
|
NDC 16571066701
|
| Hospital Charge Code |
3804029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.13
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
PHENobarbital 64.8 mg Tab [HMC]
|
Facility
|
OP
|
$7.53
|
|
|
Service Code
|
NDC 00603516721
|
| Hospital Charge Code |
3804029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$7.15 |
| Rate for Payer: Aetna Commercial |
$6.78
|
| Rate for Payer: Humana Medicare Advantage |
$3.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.01
|
| Rate for Payer: WPPA Medicare Advantage |
$4.52
|
|
|
Phenobarbital QST
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS 80184
|
| Hospital Charge Code |
3551427
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$162.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$162.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$171.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Phenobarbital QST
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
HCPCS 80184
|
| Hospital Charge Code |
3551427
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$171.00 |
| Rate for Payer: Aetna Commercial |
$162.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$53.99
|
| Rate for Payer: Humana Medicare Advantage |
$75.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$171.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.30
|
| Rate for Payer: WPPA Medicare Advantage |
$108.00
|
|
|
phenol Top 98% Swab [HMC]
|
Facility
|
OP
|
$241.05
|
|
|
Service Code
|
NDC 00884629730
|
| Hospital Charge Code |
3800318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.42 |
| Max. Negotiated Rate |
$229.00 |
| Rate for Payer: Aetna Commercial |
$216.94
|
| Rate for Payer: Humana Medicare Advantage |
$101.24
|
| Rate for Payer: UnitedHealthcare Commercial |
$229.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$96.42
|
| Rate for Payer: WPPA Medicare Advantage |
$144.63
|
|
|
phenol Top 98% Swab [HMC]
|
Facility
|
IP
|
$241.05
|
|
|
Service Code
|
NDC 00884629730
|
| Hospital Charge Code |
3800318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$216.94 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$216.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$229.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
phenol topical 1.4% Spr [HMC]
|
Facility
|
OP
|
$25.78
|
|
|
Service Code
|
NDC 00904630521
|
| Hospital Charge Code |
3809064
|
|
Hospital Revenue Code
|
257
|
| Min. Negotiated Rate |
$10.31 |
| Max. Negotiated Rate |
$24.49 |
| Rate for Payer: Aetna Commercial |
$23.20
|
| Rate for Payer: Humana Medicare Advantage |
$10.83
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.31
|
| Rate for Payer: WPPA Medicare Advantage |
$15.47
|
|
|
phenol topical 1.4% Spr [HMC]
|
Facility
|
IP
|
$26.76
|
|
|
Service Code
|
NDC 00536122858
|
| Hospital Charge Code |
3809064
|
|
Hospital Revenue Code
|
257
|
| Min. Negotiated Rate |
$24.08 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$24.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$25.42
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
phenol topical 1.4% Spr [HMC]
|
Facility
|
IP
|
$33.81
|
|
|
Service Code
|
NDC 78112001103
|
| Hospital Charge Code |
3809064
|
|
Hospital Revenue Code
|
257
|
| Min. Negotiated Rate |
$30.43 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$30.43
|
| Rate for Payer: UnitedHealthcare Commercial |
$32.12
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
