|
medroxyPROGESTERone 150 mg/mL IM Susp [HMC]
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
3800609
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$113.05 |
| Rate for Payer: Aetna Commercial |
$107.10
|
| Rate for Payer: Aetna Commercial |
$107.02
|
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.50
|
| Rate for Payer: Humana Medicare Advantage |
$49.98
|
| Rate for Payer: Humana Medicare Advantage |
$49.94
|
| Rate for Payer: Humana Medicare Advantage |
$61.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$112.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$113.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$138.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.24
|
| Rate for Payer: WPPA Medicare Advantage |
$87.60
|
| Rate for Payer: WPPA Medicare Advantage |
$71.40
|
| Rate for Payer: WPPA Medicare Advantage |
$71.35
|
|
|
medroxyPROGESTERone 5 mg Tab [HMC]
|
Facility
|
IP
|
$6.37
|
|
|
Service Code
|
NDC 00555087304
|
| Hospital Charge Code |
3806177
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.05
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
medroxyPROGESTERone 5 mg Tab [HMC]
|
Facility
|
IP
|
$6.42
|
|
|
Service Code
|
NDC 00555087302
|
| Hospital Charge Code |
3806177
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.78
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.10
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
medroxyPROGESTERone 5 mg Tab [HMC]
|
Facility
|
OP
|
$6.42
|
|
|
Service Code
|
NDC 00555087302
|
| Hospital Charge Code |
3806177
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$6.10 |
| Rate for Payer: Aetna Commercial |
$5.78
|
| Rate for Payer: Humana Medicare Advantage |
$2.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.57
|
| Rate for Payer: WPPA Medicare Advantage |
$3.85
|
|
|
medroxyPROGESTERone 5 mg Tab [HMC]
|
Facility
|
OP
|
$6.37
|
|
|
Service Code
|
NDC 00555087304
|
| Hospital Charge Code |
3806177
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$6.05 |
| Rate for Payer: Aetna Commercial |
$5.73
|
| Rate for Payer: Humana Medicare Advantage |
$2.68
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.55
|
| Rate for Payer: WPPA Medicare Advantage |
$3.82
|
|
|
megestrol 20 mg Tab [HMC]
|
Facility
|
IP
|
$8.12
|
|
|
Service Code
|
NDC 00555060602
|
| Hospital Charge Code |
3802499
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.31
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.71
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
megestrol 20 mg Tab [HMC]
|
Facility
|
OP
|
$8.12
|
|
|
Service Code
|
NDC 00555060602
|
| Hospital Charge Code |
3802499
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$7.71 |
| Rate for Payer: Aetna Commercial |
$7.31
|
| Rate for Payer: Humana Medicare Advantage |
$3.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.25
|
| Rate for Payer: WPPA Medicare Advantage |
$4.87
|
|
|
megestrol 20 mg Tab [HMC]
|
Facility
|
IP
|
$7.08
|
|
|
Service Code
|
NDC 49884028901
|
| Hospital Charge Code |
3802499
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.37 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.73
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
megestrol 20 mg Tab [HMC]
|
Facility
|
OP
|
$6.97
|
|
|
Service Code
|
NDC 51079043420
|
| Hospital Charge Code |
3802499
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$6.62 |
| Rate for Payer: Aetna Commercial |
$6.27
|
| Rate for Payer: Humana Medicare Advantage |
$2.93
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.79
|
| Rate for Payer: WPPA Medicare Advantage |
$4.18
|
|
|
megestrol 20 mg Tab [HMC]
|
Facility
|
IP
|
$6.97
|
|
|
Service Code
|
NDC 51079043420
|
| Hospital Charge Code |
3802499
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.27 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.62
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
megestrol 20 mg Tab [HMC]
|
Facility
|
OP
|
$7.08
|
|
|
Service Code
|
NDC 49884028901
|
| Hospital Charge Code |
3802499
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$6.73 |
| Rate for Payer: Aetna Commercial |
$6.37
|
| Rate for Payer: Humana Medicare Advantage |
$2.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.83
|
| Rate for Payer: WPPA Medicare Advantage |
$4.25
|
|
|
megestrol 40 mg/mL Oral Susp [HMC]
|
Facility
|
IP
|
$21.77
|
|
|
Service Code
|
NDC 69339016017
|
| Hospital Charge Code |
3808715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.59 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$19.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.68
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
megestrol 40 mg/mL Oral Susp [HMC]
|
Facility
|
OP
|
$21.77
|
|
|
Service Code
|
NDC 69339016017
|
| Hospital Charge Code |
3808715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$20.68 |
| Rate for Payer: Aetna Commercial |
$19.59
|
| Rate for Payer: Humana Medicare Advantage |
$9.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.71
|
| Rate for Payer: WPPA Medicare Advantage |
$13.06
|
|
|
megestrol 40 mg/mL Oral Susp [HMC]
|
Facility
|
IP
|
$18.45
|
|
|
Service Code
|
NDC 68094025062
|
| Hospital Charge Code |
3808715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$16.61
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.53
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
megestrol 40 mg/mL Oral Susp [HMC]
|
Facility
|
IP
|
$18.40
|
|
|
Service Code
|
NDC 68094052862
|
| Hospital Charge Code |
3808715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.56 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$16.56
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.48
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
megestrol 40 mg/mL Oral Susp [HMC]
|
Facility
|
OP
|
$18.40
|
|
|
Service Code
|
NDC 68094052862
|
| Hospital Charge Code |
3808715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$17.48 |
| Rate for Payer: Aetna Commercial |
$16.56
|
| Rate for Payer: Humana Medicare Advantage |
$7.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.36
|
| Rate for Payer: WPPA Medicare Advantage |
$11.04
|
|
|
megestrol 40 mg/mL Oral Susp [HMC]
|
Facility
|
IP
|
$21.77
|
|
|
Service Code
|
NDC 00121094540
|
| Hospital Charge Code |
3808715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.59 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$19.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.68
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
megestrol 40 mg/mL Oral Susp [HMC]
|
Facility
|
OP
|
$21.77
|
|
|
Service Code
|
NDC 00121094540
|
| Hospital Charge Code |
3808715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$20.68 |
| Rate for Payer: Aetna Commercial |
$19.59
|
| Rate for Payer: Humana Medicare Advantage |
$9.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.71
|
| Rate for Payer: WPPA Medicare Advantage |
$13.06
|
|
|
megestrol 40 mg/mL Oral Susp [HMC]
|
Facility
|
OP
|
$18.45
|
|
|
Service Code
|
NDC 68094025062
|
| Hospital Charge Code |
3808715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.38 |
| Max. Negotiated Rate |
$17.53 |
| Rate for Payer: Aetna Commercial |
$16.61
|
| Rate for Payer: Humana Medicare Advantage |
$7.75
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.38
|
| Rate for Payer: WPPA Medicare Advantage |
$11.07
|
|
|
megestrol 40 mg Tab UD [HMC]
|
Facility
|
OP
|
$9.10
|
|
|
Service Code
|
NDC 00904357161
|
| Hospital Charge Code |
3802498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.19
|
| Rate for Payer: Humana Medicare Advantage |
$3.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.64
|
| Rate for Payer: WPPA Medicare Advantage |
$5.46
|
|
|
megestrol 40 mg Tab UD [HMC]
|
Facility
|
IP
|
$9.10
|
|
|
Service Code
|
NDC 00904357161
|
| Hospital Charge Code |
3802498
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.64
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
melatonin 3 mg tab [HMC]
|
Facility
|
IP
|
$5.20
|
|
|
Service Code
|
NDC 16571087201
|
| Hospital Charge Code |
3809585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.94
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
melatonin 3 mg tab [HMC]
|
Facility
|
OP
|
$5.20
|
|
|
Service Code
|
NDC 16571087201
|
| Hospital Charge Code |
3809585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Humana Medicare Advantage |
$2.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.08
|
| Rate for Payer: WPPA Medicare Advantage |
$3.12
|
|
|
melatonin 3 mg Tab [HMC]
|
Facility
|
IP
|
$5.21
|
|
|
Service Code
|
NDC 80681008500
|
| Hospital Charge Code |
3809585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.69
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
melatonin 3 mg Tab [HMC]
|
Facility
|
OP
|
$5.21
|
|
|
Service Code
|
NDC 80681008500
|
| Hospital Charge Code |
3809585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$4.95 |
| Rate for Payer: Aetna Commercial |
$4.69
|
| Rate for Payer: Humana Medicare Advantage |
$2.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.08
|
| Rate for Payer: WPPA Medicare Advantage |
$3.13
|
|
