|
metFORMIN 750 mg ER Tab [HMC]
|
Facility
|
IP
|
$8.59
|
|
|
Service Code
|
NDC 76385012901
|
| Hospital Charge Code |
3800673
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.73 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.16
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metFORMIN 750 mg ER Tab [HMC]
|
Facility
|
IP
|
$8.63
|
|
|
Service Code
|
NDC 50268055115
|
| Hospital Charge Code |
3800673
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.77 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.77
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metFORMIN 750 mg ER Tab [HMC]
|
Facility
|
OP
|
$8.63
|
|
|
Service Code
|
NDC 50268055115
|
| Hospital Charge Code |
3800673
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$8.20 |
| Rate for Payer: Aetna Commercial |
$7.77
|
| Rate for Payer: Humana Medicare Advantage |
$3.62
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.45
|
| Rate for Payer: WPPA Medicare Advantage |
$5.18
|
|
|
metFORMIN 750 mg ER Tab [HMC]
|
Facility
|
OP
|
$8.59
|
|
|
Service Code
|
NDC 67877041401
|
| Hospital Charge Code |
3800673
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$8.16 |
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Humana Medicare Advantage |
$3.61
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.44
|
| Rate for Payer: WPPA Medicare Advantage |
$5.15
|
|
|
metFORMIN 850 mg Tab UD [HMC]
|
Facility
|
OP
|
$5.75
|
|
|
Service Code
|
NDC 00904716361
|
| Hospital Charge Code |
3800352
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$5.46 |
| Rate for Payer: Aetna Commercial |
$5.17
|
| Rate for Payer: Humana Medicare Advantage |
$2.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.30
|
| Rate for Payer: WPPA Medicare Advantage |
$3.45
|
|
|
metFORMIN 850 mg Tab UD [HMC]
|
Facility
|
IP
|
$5.75
|
|
|
Service Code
|
NDC 00904716361
|
| Hospital Charge Code |
3800352
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.17 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.46
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
methacholine 100 mg Inh Pwdr for Recon [HMC]
|
Facility
|
IP
|
$169.40
|
|
|
Service Code
|
HCPCS J7674
|
| Hospital Charge Code |
3800231
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$152.46 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$152.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$160.93
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
methacholine 100 mg Inh Pwdr for Recon [HMC]
|
Facility
|
OP
|
$169.40
|
|
|
Service Code
|
HCPCS J7674
|
| Hospital Charge Code |
3800231
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$160.93 |
| Rate for Payer: Aetna Commercial |
$152.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.44
|
| Rate for Payer: Humana Medicare Advantage |
$71.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$160.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.90
|
| Rate for Payer: WPPA Medicare Advantage |
$101.64
|
|
|
methadone 10 mg Tab [HMC]
|
Facility
|
OP
|
$6.57
|
|
|
Service Code
|
HCPCS S0109
|
| Hospital Charge Code |
3805745
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$6.24 |
| Rate for Payer: Aetna Commercial |
$5.91
|
| Rate for Payer: Aetna Commercial |
$5.33
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.32
|
| Rate for Payer: Humana Medicare Advantage |
$2.49
|
| Rate for Payer: Humana Medicare Advantage |
$2.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.24
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.03
|
| Rate for Payer: WPPA Medicare Advantage |
$3.55
|
| Rate for Payer: WPPA Medicare Advantage |
$3.94
|
|
|
methadone 10 mg Tab [HMC]
|
Facility
|
IP
|
$5.92
|
|
|
Service Code
|
HCPCS S0109
|
| Hospital Charge Code |
3805745
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.33 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.33
|
| Rate for Payer: Aetna Commercial |
$5.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.62
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.24
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
methimazole 5 mg Tab [HMC]
|
Facility
|
OP
|
$6.33
|
|
|
Service Code
|
NDC 23155007001
|
| Hospital Charge Code |
3800953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$6.01 |
| Rate for Payer: Aetna Commercial |
$5.70
|
| Rate for Payer: Humana Medicare Advantage |
$2.66
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.53
|
| Rate for Payer: WPPA Medicare Advantage |
$3.80
|
|
|
methimazole 5 mg Tab [HMC]
|
Facility
|
IP
|
$6.33
|
|
|
Service Code
|
NDC 23155007001
|
| Hospital Charge Code |
3800953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.01
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
methimazole 5 mg Tab [HMC]
|
Facility
|
OP
|
$6.80
|
|
|
Service Code
|
NDC 60687035701
|
| Hospital Charge Code |
3800953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$6.46 |
| Rate for Payer: Aetna Commercial |
$6.12
|
| Rate for Payer: Humana Medicare Advantage |
$2.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.72
|
| Rate for Payer: WPPA Medicare Advantage |
$4.08
|
|
|
methimazole 5 mg Tab [HMC]
|
Facility
|
OP
|
$6.33
|
|
|
Service Code
|
NDC 49884064001
|
| Hospital Charge Code |
3800953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.53 |
| Max. Negotiated Rate |
$6.01 |
| Rate for Payer: Aetna Commercial |
$5.70
|
| Rate for Payer: Humana Medicare Advantage |
$2.66
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.53
|
| Rate for Payer: WPPA Medicare Advantage |
$3.80
|
|
|
methimazole 5 mg Tab [HMC]
|
Facility
|
IP
|
$6.33
|
|
|
Service Code
|
NDC 49884064001
|
| Hospital Charge Code |
3800953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.01
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
methimazole 5 mg Tab [HMC]
|
Facility
|
IP
|
$6.80
|
|
|
Service Code
|
NDC 60687035701
|
| Hospital Charge Code |
3800953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.46
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
methIMAzole 5 mg Tab [HMC]
|
Facility
|
OP
|
$7.15
|
|
|
Service Code
|
NDC 60687066901
|
| Hospital Charge Code |
3800953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Aetna Commercial |
$6.43
|
| Rate for Payer: Humana Medicare Advantage |
$3.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.86
|
| Rate for Payer: WPPA Medicare Advantage |
$4.29
|
|
|
methIMAzole 5 mg Tab [HMC]
|
Facility
|
IP
|
$7.15
|
|
|
Service Code
|
NDC 60687066901
|
| Hospital Charge Code |
3800953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.43 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.43
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.79
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
methocarbamol 500 mg Tab [HMC]
|
Facility
|
IP
|
$5.85
|
|
|
Service Code
|
NDC 63739099110
|
| Hospital Charge Code |
3803654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.26 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.26
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.56
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
methocarbamol 500 mg Tab [HMC]
|
Facility
|
OP
|
$6.53
|
|
|
Service Code
|
NDC 76385012301
|
| Hospital Charge Code |
3803654
|
|
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
|
|
|
methocarbamol 500 mg Tab [HMC]
|
Facility
|
OP
|
$5.85
|
|
|
Service Code
|
NDC 63739099110
|
| Hospital Charge Code |
3803654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: Aetna Commercial |
$5.26
|
| Rate for Payer: Humana Medicare Advantage |
$2.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.34
|
| Rate for Payer: WPPA Medicare Advantage |
$3.51
|
|
|
methocarbamol 500 mg Tab [HMC]
|
Facility
|
OP
|
$5.95
|
|
|
Service Code
|
NDC 00904705761
|
| Hospital Charge Code |
3803654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$5.65 |
| Rate for Payer: Aetna Commercial |
$5.36
|
| Rate for Payer: Humana Medicare Advantage |
$2.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.38
|
| Rate for Payer: WPPA Medicare Advantage |
$3.57
|
|
|
methocarbamol 500 mg Tab [HMC]
|
Facility
|
IP
|
$6.53
|
|
|
Service Code
|
NDC 76385012301
|
| Hospital Charge Code |
3803654
|
|
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
|
|
|
methocarbamol 500 mg Tab [HMC]
|
Facility
|
IP
|
$5.95
|
|
|
Service Code
|
NDC 00904705761
|
| Hospital Charge Code |
3803654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.36 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.65
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
methotrexate 2.5 mg Tab [HMC]
|
Facility
|
IP
|
$15.69
|
|
|
Service Code
|
HCPCS J8610
|
| Hospital Charge Code |
3859552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.12 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$14.12
|
| Rate for Payer: Aetna Commercial |
$18.53
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.56
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.91
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
