|
bumetanide 1 mg Tab [HMC]
|
Facility
|
IP
|
$9.42
|
|
|
Service Code
|
NDC 00904701661
|
| Hospital Charge Code |
3800367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.48 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.48
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bumetanide 1 mg Tab [HMC]
|
Facility
|
OP
|
$8.27
|
|
|
Service Code
|
NDC 00185012901
|
| Hospital Charge Code |
3800367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$7.86 |
| Rate for Payer: Aetna Commercial |
$7.44
|
| Rate for Payer: Humana Medicare Advantage |
$3.47
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.31
|
| Rate for Payer: WPPA Medicare Advantage |
$4.96
|
|
|
bumetanide 1 mg Tab [HMC]
|
Facility
|
IP
|
$12.30
|
|
|
Service Code
|
NDC 00904701604
|
| Hospital Charge Code |
3800367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.07 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$11.07
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.69
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bumetanide 1 mg Tab [HMC]
|
Facility
|
OP
|
$12.30
|
|
|
Service Code
|
NDC 00904701604
|
| Hospital Charge Code |
3800367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$11.69 |
| Rate for Payer: Aetna Commercial |
$11.07
|
| Rate for Payer: Humana Medicare Advantage |
$5.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.92
|
| Rate for Payer: WPPA Medicare Advantage |
$7.38
|
|
|
bumetanide 1 mg Tab [HMC]
|
Facility
|
OP
|
$9.42
|
|
|
Service Code
|
NDC 00904701661
|
| Hospital Charge Code |
3800367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.77 |
| Max. Negotiated Rate |
$8.95 |
| Rate for Payer: Aetna Commercial |
$8.48
|
| Rate for Payer: Humana Medicare Advantage |
$3.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.77
|
| Rate for Payer: WPPA Medicare Advantage |
$5.65
|
|
|
bumetanide 1 mg Tab [HMC]
|
Facility
|
OP
|
$8.84
|
|
|
Service Code
|
NDC 00904701606
|
| Hospital Charge Code |
3800367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$8.40 |
| Rate for Payer: Aetna Commercial |
$7.96
|
| Rate for Payer: Humana Medicare Advantage |
$3.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.54
|
| Rate for Payer: WPPA Medicare Advantage |
$5.30
|
|
|
bumetanide 1 mg Tab [HMC]
|
Facility
|
IP
|
$8.27
|
|
|
Service Code
|
NDC 00185012901
|
| Hospital Charge Code |
3800367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.44 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.86
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bumetanide 1 mg Tab [HMC]
|
Facility
|
IP
|
$8.84
|
|
|
Service Code
|
NDC 00904701606
|
| Hospital Charge Code |
3800367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.96 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.40
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bumetanide 2 mg Tab [HMC]
|
Facility
|
OP
|
$11.17
|
|
|
Service Code
|
NDC 50268013215
|
| Hospital Charge Code |
3809065
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.47 |
| Max. Negotiated Rate |
$10.61 |
| Rate for Payer: Aetna Commercial |
$10.05
|
| Rate for Payer: Humana Medicare Advantage |
$4.69
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.47
|
| Rate for Payer: WPPA Medicare Advantage |
$6.70
|
|
|
bumetanide 2 mg Tab [HMC]
|
Facility
|
IP
|
$11.17
|
|
|
Service Code
|
NDC 50268013215
|
| Hospital Charge Code |
3809065
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.61
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bumetanide 2 mg Tab [HMC]
|
Facility
|
OP
|
$13.81
|
|
|
Service Code
|
NDC 42799012101
|
| Hospital Charge Code |
3809065
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.52 |
| Max. Negotiated Rate |
$13.12 |
| Rate for Payer: Aetna Commercial |
$12.43
|
| Rate for Payer: Humana Medicare Advantage |
$5.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.52
|
| Rate for Payer: WPPA Medicare Advantage |
$8.29
|
|
|
bumetanide 2 mg Tab [HMC]
|
Facility
|
IP
|
$13.81
|
|
|
Service Code
|
NDC 42799012101
|
| Hospital Charge Code |
3809065
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$12.43
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.12
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bumetanide 2 mg Tab [HMC]
|
Facility
|
OP
|
$10.31
|
|
|
Service Code
|
NDC 60687053501
|
| Hospital Charge Code |
3809065
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna Commercial |
$9.28
|
| Rate for Payer: Humana Medicare Advantage |
$4.33
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.12
|
| Rate for Payer: WPPA Medicare Advantage |
$6.19
|
|
|
bumetanide 2 mg Tab [HMC]
|
Facility
|
IP
|
$10.31
|
|
|
Service Code
|
NDC 60687053501
|
| Hospital Charge Code |
3809065
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.79
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bupivacaine 0.25% PF Inj Sol 10 mL [HMC]
|
Facility
|
OP
|
$35.60
|
|
|
Service Code
|
NDC 55150016710
|
| Hospital Charge Code |
3800848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.24 |
| Max. Negotiated Rate |
$33.82 |
| Rate for Payer: Aetna Commercial |
$32.04
|
| Rate for Payer: Humana Medicare Advantage |
$14.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.24
|
| Rate for Payer: WPPA Medicare Advantage |
$21.36
|
|
|
bupivacaine 0.25% PF Inj Sol 10 mL [HMC]
|
Facility
|
IP
|
$31.86
|
|
|
Service Code
|
NDC 00409115901
|
| Hospital Charge Code |
3800848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.67 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$28.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.27
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bupivacaine 0.25% PF Inj Sol 10 mL [HMC]
|
Facility
|
IP
|
$44.19
|
|
|
Service Code
|
NDC 00409155910
|
| Hospital Charge Code |
3800848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.77 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$39.77
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.98
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bupivacaine 0.25% PF Inj Sol 10 mL [HMC]
|
Facility
|
OP
|
$44.19
|
|
|
Service Code
|
NDC 00409155910
|
| Hospital Charge Code |
3800848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.68 |
| Max. Negotiated Rate |
$41.98 |
| Rate for Payer: Aetna Commercial |
$39.77
|
| Rate for Payer: Humana Medicare Advantage |
$18.56
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.68
|
| Rate for Payer: WPPA Medicare Advantage |
$26.51
|
|
|
bupivacaine 0.25% PF Inj Sol 10 mL [HMC]
|
Facility
|
IP
|
$35.60
|
|
|
Service Code
|
NDC 55150016710
|
| Hospital Charge Code |
3800848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.04 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$32.04
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.82
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bupivacaine 0.25% PF Inj Sol 10 mL [HMC]
|
Facility
|
OP
|
$31.86
|
|
|
Service Code
|
NDC 00409115901
|
| Hospital Charge Code |
3800848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$30.27 |
| Rate for Payer: Aetna Commercial |
$28.67
|
| Rate for Payer: Humana Medicare Advantage |
$13.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.74
|
| Rate for Payer: WPPA Medicare Advantage |
$19.12
|
|
|
bupivacaine 0.25% PF Inj Sol 30 mL [HMC]
|
Facility
|
OP
|
$36.79
|
|
|
Service Code
|
NDC 00409155930
|
| Hospital Charge Code |
3800377
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$34.95 |
| Rate for Payer: Aetna Commercial |
$33.11
|
| Rate for Payer: Humana Medicare Advantage |
$15.45
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.72
|
| Rate for Payer: WPPA Medicare Advantage |
$22.07
|
|
|
bupivacaine 0.25% PF Inj Sol 30 mL [HMC]
|
Facility
|
IP
|
$47.07
|
|
|
Service Code
|
NDC 63323046437
|
| Hospital Charge Code |
3800377
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.36 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$42.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$44.72
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bupivacaine 0.25% PF Inj Sol 30 mL [HMC]
|
Facility
|
IP
|
$36.79
|
|
|
Service Code
|
NDC 00409155930
|
| Hospital Charge Code |
3800377
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.11 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$33.11
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
bupivacaine 0.25% PF Inj Sol 30 mL [HMC]
|
Facility
|
OP
|
$30.39
|
|
|
Service Code
|
NDC 00409115910
|
| Hospital Charge Code |
3800377
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.16 |
| Max. Negotiated Rate |
$28.87 |
| Rate for Payer: Aetna Commercial |
$27.35
|
| Rate for Payer: Humana Medicare Advantage |
$12.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.16
|
| Rate for Payer: WPPA Medicare Advantage |
$18.23
|
|
|
bupivacaine 0.25% PF Inj Sol 30 mL [HMC]
|
Facility
|
IP
|
$30.39
|
|
|
Service Code
|
NDC 00409115910
|
| Hospital Charge Code |
3800377
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.35 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$27.35
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.87
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
