|
methylPREDNISolone 80 mg/mL Inj Susp [HMC]
|
Facility
|
IP
|
$59.17
|
|
|
Service Code
|
NDC 70121155205
|
| Hospital Charge Code |
3807135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.25 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$53.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$56.21
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
methylPREDNISolone 80 mg/mL Inj Susp [HMC]
|
Facility
|
OP
|
$59.17
|
|
|
Service Code
|
NDC 70121155205
|
| Hospital Charge Code |
3807135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.67 |
| Max. Negotiated Rate |
$56.21 |
| Rate for Payer: Aetna Commercial |
$53.25
|
| Rate for Payer: Humana Medicare Advantage |
$24.85
|
| Rate for Payer: UnitedHealthcare Commercial |
$56.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.67
|
| Rate for Payer: WPPA Medicare Advantage |
$35.50
|
|
|
methylPREDNISolone 80 mg/mL Susp [HMC]
|
Facility
|
OP
|
$55.50
|
|
|
Service Code
|
HCPCS J1010
|
| Hospital Charge Code |
3807135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$52.73 |
| Rate for Payer: Aetna Commercial |
$49.95
|
| Rate for Payer: Humana Medicare Advantage |
$23.31
|
| Rate for Payer: UnitedHealthcare Commercial |
$52.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.12
|
| Rate for Payer: WPPA Medicare Advantage |
$33.30
|
|
|
methylPREDNISolone 80 mg/mL Susp [HMC]
|
Facility
|
IP
|
$55.50
|
|
|
Service Code
|
HCPCS J1010
|
| Hospital Charge Code |
3807135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.95 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$49.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$52.73
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metoclopramide 10 mg Tab [HMC]
|
Facility
|
OP
|
$7.16
|
|
|
Service Code
|
NDC 60687063101
|
| Hospital Charge Code |
3803605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Aetna Commercial |
$6.44
|
| Rate for Payer: Humana Medicare Advantage |
$3.01
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.86
|
| Rate for Payer: WPPA Medicare Advantage |
$4.30
|
|
|
metoclopramide 10 mg Tab [HMC]
|
Facility
|
IP
|
$7.16
|
|
|
Service Code
|
NDC 60687063101
|
| Hospital Charge Code |
3803605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metoclopramide 10 mg Tab [HMC]
|
Facility
|
IP
|
$7.16
|
|
|
Service Code
|
NDC 68084067601
|
| Hospital Charge Code |
3803605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metoclopramide 10 mg Tab [HMC]
|
Facility
|
OP
|
$7.16
|
|
|
Service Code
|
NDC 68084067601
|
| Hospital Charge Code |
3803605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Aetna Commercial |
$6.44
|
| Rate for Payer: Humana Medicare Advantage |
$3.01
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.86
|
| Rate for Payer: WPPA Medicare Advantage |
$4.30
|
|
|
metoclopramide 5 mg/5 mL Oral Syrup [HMC]
|
Facility
|
OP
|
$59.79
|
|
|
Service Code
|
NDC 00121057616
|
| Hospital Charge Code |
3800328
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.92 |
| Max. Negotiated Rate |
$56.80 |
| Rate for Payer: Aetna Commercial |
$53.81
|
| Rate for Payer: Humana Medicare Advantage |
$25.11
|
| Rate for Payer: UnitedHealthcare Commercial |
$56.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.92
|
| Rate for Payer: WPPA Medicare Advantage |
$35.87
|
|
|
metoclopramide 5 mg/5 mL Oral Syrup [HMC]
|
Facility
|
IP
|
$59.79
|
|
|
Service Code
|
NDC 00121057616
|
| Hospital Charge Code |
3800328
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.81 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$53.81
|
| Rate for Payer: UnitedHealthcare Commercial |
$56.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metoclopramide 5 mg/mL Inj Sol [HMC]
|
Facility
|
IP
|
$27.45
|
|
|
Service Code
|
NDC 00409341411
|
| Hospital Charge Code |
3806235
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.08
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metoclopramide 5 mg/mL Inj Sol [HMC]
|
Facility
|
IP
|
$27.45
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
3806235
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Commercial |
$36.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.08
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metoclopramide 5 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$27.45
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
3806235
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$26.08 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Commercial |
$36.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.33
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.33
|
| Rate for Payer: Humana Medicare Advantage |
$16.85
|
| Rate for Payer: Humana Medicare Advantage |
$11.53
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.08
|
| Rate for Payer: WPPA Medicare Advantage |
$24.07
|
| Rate for Payer: WPPA Medicare Advantage |
$16.47
|
|
|
metoclopramide 5 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$27.45
|
|
|
Service Code
|
NDC 00409341411
|
| Hospital Charge Code |
3806235
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$26.08 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Humana Medicare Advantage |
$11.53
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.98
|
| Rate for Payer: WPPA Medicare Advantage |
$16.47
|
|
|
metolazone 2.5 mg Tab [HMC]
|
Facility
|
OP
|
$11.22
|
|
|
Service Code
|
NDC 00185505001
|
| Hospital Charge Code |
3802051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.49 |
| Max. Negotiated Rate |
$10.66 |
| Rate for Payer: Aetna Commercial |
$10.10
|
| Rate for Payer: Humana Medicare Advantage |
$4.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.49
|
| Rate for Payer: WPPA Medicare Advantage |
$6.73
|
|
|
metolazone 2.5 mg Tab [HMC]
|
Facility
|
IP
|
$11.22
|
|
|
Service Code
|
NDC 00185505001
|
| Hospital Charge Code |
3802051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.10 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.66
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metolazone 2.5 mg Tab [HMC]
|
Facility
|
IP
|
$14.86
|
|
|
Service Code
|
NDC 51079002320
|
| Hospital Charge Code |
3802051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.37 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$13.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.12
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metolazone 2.5 mg Tab [HMC]
|
Facility
|
OP
|
$14.86
|
|
|
Service Code
|
NDC 51079002320
|
| Hospital Charge Code |
3802051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$14.12 |
| Rate for Payer: Aetna Commercial |
$13.37
|
| Rate for Payer: Humana Medicare Advantage |
$6.24
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.94
|
| Rate for Payer: WPPA Medicare Advantage |
$8.92
|
|
|
metoprolol 1 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$36.17
|
|
|
Service Code
|
NDC 00143987310
|
| Hospital Charge Code |
3806243
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.47 |
| Max. Negotiated Rate |
$34.36 |
| Rate for Payer: Aetna Commercial |
$32.55
|
| Rate for Payer: Humana Medicare Advantage |
$15.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.47
|
| Rate for Payer: WPPA Medicare Advantage |
$21.70
|
|
|
metoprolol 1 mg/mL Inj Sol [HMC]
|
Facility
|
IP
|
$36.17
|
|
|
Service Code
|
NDC 00143987310
|
| Hospital Charge Code |
3806243
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.55 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$32.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.36
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metoprolol succinate 100 mg ER Tab [HMC]
|
Facility
|
IP
|
$10.02
|
|
|
Service Code
|
NDC 50268054215
|
| Hospital Charge Code |
3800832
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.02 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.52
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metoprolol succinate 100 mg ER Tab [HMC]
|
Facility
|
IP
|
$10.59
|
|
|
Service Code
|
NDC 00904632461
|
| Hospital Charge Code |
3800832
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.53
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.06
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metoprolol succinate 100 mg ER Tab [HMC]
|
Facility
|
OP
|
$10.02
|
|
|
Service Code
|
NDC 50268054215
|
| Hospital Charge Code |
3800832
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.01 |
| Max. Negotiated Rate |
$9.52 |
| Rate for Payer: Aetna Commercial |
$9.02
|
| Rate for Payer: Humana Medicare Advantage |
$4.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.01
|
| Rate for Payer: WPPA Medicare Advantage |
$6.01
|
|
|
metoprolol succinate 100 mg ER Tab [HMC]
|
Facility
|
IP
|
$9.75
|
|
|
Service Code
|
NDC 45963067711
|
| Hospital Charge Code |
3800832
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.78 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.78
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.26
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
metoprolol succinate 100 mg ER Tab [HMC]
|
Facility
|
IP
|
$10.02
|
|
|
Service Code
|
NDC 60687041301
|
| Hospital Charge Code |
3800832
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.02 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.52
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
