|
hydrALAZINE 25 mg Tab [HMC]
|
Facility
|
IP
|
$6.53
|
|
|
Service Code
|
NDC 51079007520
|
| Hospital Charge Code |
3805666
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
hydrALAZINE 25 mg Tab [HMC]
|
Facility
|
IP
|
$5.86
|
|
|
Service Code
|
NDC 00904744861
|
| Hospital Charge Code |
3805666
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.27 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.57
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
hydrALAZINE 25 mg Tab [HMC]
|
Facility
|
OP
|
$5.86
|
|
|
Service Code
|
NDC 00904744861
|
| Hospital Charge Code |
3805666
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$5.57 |
| Rate for Payer: Aetna Commercial |
$5.27
|
| Rate for Payer: Humana Medicare Advantage |
$2.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.34
|
| Rate for Payer: WPPA Medicare Advantage |
$3.52
|
|
|
hydrALAZINE 25 mg Tab [HMC]
|
Facility
|
OP
|
$5.45
|
|
|
Service Code
|
NDC 00904644161
|
| Hospital Charge Code |
3805666
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$5.18 |
| Rate for Payer: Aetna Commercial |
$4.91
|
| Rate for Payer: Humana Medicare Advantage |
$2.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.18
|
| Rate for Payer: WPPA Medicare Advantage |
$3.27
|
|
|
hydrALAZINE 25 mg Tab [HMC]
|
Facility
|
OP
|
$6.52
|
|
|
Service Code
|
NDC 23155083301
|
| Hospital Charge Code |
3805666
|
|
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
|
|
|
hydrALAZINE 25 mg Tab [HMC]
|
Facility
|
IP
|
$6.52
|
|
|
Service Code
|
NDC 23155083301
|
| Hospital Charge Code |
3805666
|
|
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
|
|
|
hydrALAZINE 25 mg Tab [HMC]
|
Facility
|
OP
|
$6.53
|
|
|
Service Code
|
NDC 51079007520
|
| Hospital Charge Code |
3805666
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$6.20 |
| Rate for Payer: Aetna Commercial |
$5.88
|
| Rate for Payer: Humana Medicare Advantage |
$2.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.61
|
| Rate for Payer: WPPA Medicare Advantage |
$3.92
|
|
|
hydrALAZINE 25 mg Tab [HMC]
|
Facility
|
IP
|
$5.76
|
|
|
Service Code
|
NDC 60687082201
|
| Hospital Charge Code |
3805666
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.47
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
hydrALAZINE 25 mg Tab [HMC]
|
Facility
|
IP
|
$5.45
|
|
|
Service Code
|
NDC 00904644161
|
| Hospital Charge Code |
3805666
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.91 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.18
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
hydroCHLOROthiazide 12.5 mg Tab [HMC]
|
Facility
|
OP
|
$6.21
|
|
|
Service Code
|
NDC 16729018217
|
| Hospital Charge Code |
3800517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$5.90 |
| Rate for Payer: Aetna Commercial |
$5.59
|
| Rate for Payer: Humana Medicare Advantage |
$2.61
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.48
|
| Rate for Payer: WPPA Medicare Advantage |
$3.73
|
|
|
hydroCHLOROthiazide 12.5 mg Tab [HMC]
|
Facility
|
OP
|
$7.47
|
|
|
Service Code
|
NDC 23155076401
|
| Hospital Charge Code |
3800517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$7.10 |
| Rate for Payer: Aetna Commercial |
$6.72
|
| Rate for Payer: Humana Medicare Advantage |
$3.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.99
|
| Rate for Payer: WPPA Medicare Advantage |
$4.48
|
|
|
hydroCHLOROthiazide 12.5 mg Tab [HMC]
|
Facility
|
IP
|
$7.47
|
|
|
Service Code
|
NDC 23155076401
|
| Hospital Charge Code |
3800517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.72 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.10
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
hydroCHLOROthiazide 12.5 mg Tab [HMC]
|
Facility
|
OP
|
$5.50
|
|
|
Service Code
|
NDC 69315015501
|
| Hospital Charge Code |
3800517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: Aetna Commercial |
$4.95
|
| Rate for Payer: Humana Medicare Advantage |
$2.31
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.20
|
| Rate for Payer: WPPA Medicare Advantage |
$3.30
|
|
|
hydroCHLOROthiazide 12.5 mg Tab [HMC]
|
Facility
|
IP
|
$6.21
|
|
|
Service Code
|
NDC 16729018217
|
| Hospital Charge Code |
3800517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.59 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.90
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
hydroCHLOROthiazide 12.5 mg Tab [HMC]
|
Facility
|
IP
|
$5.50
|
|
|
Service Code
|
NDC 69315015501
|
| Hospital Charge Code |
3800517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.22
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
hydrochlorothiazide 25 mg Tab [HMC]
|
Facility
|
IP
|
$5.44
|
|
|
Service Code
|
NDC 00172208310
|
| Hospital Charge Code |
3801880
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.17
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
hydrochlorothiazide 25 mg Tab [HMC]
|
Facility
|
OP
|
$5.25
|
|
|
Service Code
|
NDC 16729018301
|
| Hospital Charge Code |
3801880
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.99 |
| Rate for Payer: Aetna Commercial |
$4.72
|
| Rate for Payer: Humana Medicare Advantage |
$2.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.10
|
| Rate for Payer: WPPA Medicare Advantage |
$3.15
|
|
|
hydrochlorothiazide 25 mg Tab [HMC]
|
Facility
|
OP
|
$5.76
|
|
|
Service Code
|
NDC 60687059301
|
| Hospital Charge Code |
3801880
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$5.47 |
| Rate for Payer: Aetna Commercial |
$5.18
|
| Rate for Payer: Humana Medicare Advantage |
$2.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.30
|
| Rate for Payer: WPPA Medicare Advantage |
$3.46
|
|
|
hydrochlorothiazide 25 mg Tab [HMC]
|
Facility
|
IP
|
$5.76
|
|
|
Service Code
|
NDC 60687059301
|
| Hospital Charge Code |
3801880
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.47
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
hydrochlorothiazide 25 mg Tab [HMC]
|
Facility
|
IP
|
$5.25
|
|
|
Service Code
|
NDC 16729018301
|
| Hospital Charge Code |
3801880
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.72 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.99
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
hydrochlorothiazide 25 mg Tab [HMC]
|
Facility
|
OP
|
$5.44
|
|
|
Service Code
|
NDC 00172208310
|
| Hospital Charge Code |
3801880
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$5.17 |
| Rate for Payer: Aetna Commercial |
$4.90
|
| Rate for Payer: Humana Medicare Advantage |
$2.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.18
|
| Rate for Payer: WPPA Medicare Advantage |
$3.26
|
|
|
hydrochlorothiazide-triamterene 25 mg-37.5 mg Cap [HMC]
|
Facility
|
IP
|
$6.36
|
|
|
Service Code
|
NDC 51079093520
|
| Hospital Charge Code |
3807522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.04
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
hydrochlorothiazide-triamterene 25 mg-37.5 mg Cap [HMC]
|
Facility
|
OP
|
$6.36
|
|
|
Service Code
|
NDC 51079093520
|
| Hospital Charge Code |
3807522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Aetna Commercial |
$5.72
|
| Rate for Payer: Humana Medicare Advantage |
$2.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.54
|
| Rate for Payer: WPPA Medicare Advantage |
$3.82
|
|
|
hydrochlorothiazide-triamterene 25 mg-37.5 mg Tab UD [HMC]
|
Facility
|
IP
|
$7.96
|
|
|
Service Code
|
NDC 68084075025
|
| Hospital Charge Code |
3807522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.56
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
hydrochlorothiazide-triamterene 25 mg-37.5 mg Tab UD [HMC]
|
Facility
|
OP
|
$7.96
|
|
|
Service Code
|
NDC 68084075025
|
| Hospital Charge Code |
3807522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.18 |
| Max. Negotiated Rate |
$7.56 |
| Rate for Payer: Aetna Commercial |
$7.16
|
| Rate for Payer: Humana Medicare Advantage |
$3.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.18
|
| Rate for Payer: WPPA Medicare Advantage |
$4.78
|
|
