|
niMODipine 30 mg Cap [HMC]
|
Facility
|
OP
|
$43.47
|
|
|
Service Code
|
NDC 69452020913
|
| Hospital Charge Code |
3800875
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.39 |
| Max. Negotiated Rate |
$41.30 |
| Rate for Payer: Aetna Commercial |
$39.12
|
| Rate for Payer: Humana Medicare Advantage |
$18.26
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.39
|
| Rate for Payer: WPPA Medicare Advantage |
$26.08
|
|
|
niMODipine 30 mg Cap [HMC]
|
Facility
|
IP
|
$43.47
|
|
|
Service Code
|
NDC 69452020913
|
| Hospital Charge Code |
3800875
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.12 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$39.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.30
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nitrofurantoin macrocrystals 100 mg Cap [HMC]
|
Facility
|
IP
|
$15.13
|
|
|
Service Code
|
NDC 47781030801
|
| Hospital Charge Code |
3808157
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.62 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$13.62
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.37
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nitrofurantoin macrocrystals 100 mg Cap [HMC]
|
Facility
|
OP
|
$15.34
|
|
|
Service Code
|
NDC 50268062415
|
| Hospital Charge Code |
3808157
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$14.57 |
| Rate for Payer: Aetna Commercial |
$13.81
|
| Rate for Payer: Humana Medicare Advantage |
$6.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.14
|
| Rate for Payer: WPPA Medicare Advantage |
$9.20
|
|
|
nitrofurantoin macrocrystals 100 mg Cap [HMC]
|
Facility
|
OP
|
$15.13
|
|
|
Service Code
|
NDC 47781030801
|
| Hospital Charge Code |
3808157
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.05 |
| Max. Negotiated Rate |
$14.37 |
| Rate for Payer: Aetna Commercial |
$13.62
|
| Rate for Payer: Humana Medicare Advantage |
$6.35
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.05
|
| Rate for Payer: WPPA Medicare Advantage |
$9.08
|
|
|
nitrofurantoin macrocrystals 100 mg Cap [HMC]
|
Facility
|
IP
|
$15.34
|
|
|
Service Code
|
NDC 50268062415
|
| Hospital Charge Code |
3808157
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.81 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$13.81
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.57
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nitrofurantoin macrocrystals 50 mg Cap [HMC]
|
Facility
|
IP
|
$11.43
|
|
|
Service Code
|
NDC 00093213093
|
| Hospital Charge Code |
3809387
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.86
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nitrofurantoin macrocrystals 50 mg Cap [HMC]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 00115164301
|
| Hospital Charge Code |
3809387
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.56 |
| Max. Negotiated Rate |
$10.83 |
| Rate for Payer: Aetna Commercial |
$10.26
|
| Rate for Payer: Humana Medicare Advantage |
$4.79
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.56
|
| Rate for Payer: WPPA Medicare Advantage |
$6.84
|
|
|
nitrofurantoin macrocrystals 50 mg Cap [HMC]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 00115164301
|
| Hospital Charge Code |
3809387
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.26 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.26
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.83
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nitrofurantoin macrocrystals 50 mg Cap [HMC]
|
Facility
|
IP
|
$18.25
|
|
|
Service Code
|
NDC 50268062315
|
| Hospital Charge Code |
3809387
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.43 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$16.43
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.34
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nitrofurantoin macrocrystals 50 mg Cap [HMC]
|
Facility
|
OP
|
$18.25
|
|
|
Service Code
|
NDC 50268062315
|
| Hospital Charge Code |
3809387
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.30 |
| Max. Negotiated Rate |
$17.34 |
| Rate for Payer: Aetna Commercial |
$16.43
|
| Rate for Payer: Humana Medicare Advantage |
$7.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.30
|
| Rate for Payer: WPPA Medicare Advantage |
$10.95
|
|
|
nitrofurantoin macrocrystals 50 mg Cap [HMC]
|
Facility
|
OP
|
$11.43
|
|
|
Service Code
|
NDC 00093213093
|
| Hospital Charge Code |
3809387
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.57 |
| Max. Negotiated Rate |
$10.86 |
| Rate for Payer: Aetna Commercial |
$10.29
|
| Rate for Payer: Humana Medicare Advantage |
$4.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.57
|
| Rate for Payer: WPPA Medicare Advantage |
$6.86
|
|
|
nitroglycerin 0.2 mg/hr Transderm ER Film [HMC]
|
Facility
|
IP
|
$10.71
|
|
|
Service Code
|
NDC 00378910493
|
| Hospital Charge Code |
3805245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.64
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.17
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nitroglycerin 0.2 mg/hr Transderm ER Film [HMC]
|
Facility
|
OP
|
$10.71
|
|
|
Service Code
|
NDC 00378910493
|
| Hospital Charge Code |
3805245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.28 |
| Max. Negotiated Rate |
$10.17 |
| Rate for Payer: Aetna Commercial |
$9.64
|
| Rate for Payer: Humana Medicare Advantage |
$4.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.28
|
| Rate for Payer: WPPA Medicare Advantage |
$6.43
|
|
|
nitroglycerin 0.4 mg/hr Transderm ER Film [HMC]
|
Facility
|
IP
|
$11.52
|
|
|
Service Code
|
NDC 00378911293
|
| Hospital Charge Code |
3805252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.37 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.94
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nitroglycerin 0.4 mg/hr Transderm ER Film [HMC]
|
Facility
|
OP
|
$11.52
|
|
|
Service Code
|
NDC 00378911293
|
| Hospital Charge Code |
3805252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.61 |
| Max. Negotiated Rate |
$10.94 |
| Rate for Payer: Aetna Commercial |
$10.37
|
| Rate for Payer: Humana Medicare Advantage |
$4.84
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.61
|
| Rate for Payer: WPPA Medicare Advantage |
$6.91
|
|
|
nitroglycerin 0.4 mg sublingual Tab [HMC]
|
Facility
|
IP
|
$8.08
|
|
|
Service Code
|
NDC 70756001402
|
| Hospital Charge Code |
3802946
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.27 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.68
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nitroglycerin 0.4 mg sublingual Tab [HMC]
|
Facility
|
OP
|
$8.08
|
|
|
Service Code
|
NDC 70756001402
|
| Hospital Charge Code |
3802946
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$7.68 |
| Rate for Payer: Aetna Commercial |
$7.27
|
| Rate for Payer: Humana Medicare Advantage |
$3.39
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.23
|
| Rate for Payer: WPPA Medicare Advantage |
$4.85
|
|
|
nitroglycerin 0.4 mg sublingual Tab [HMC]
|
Facility
|
IP
|
$10.82
|
|
|
Service Code
|
NDC 58151031052
|
| Hospital Charge Code |
3802946
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.28
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nitroglycerin 0.4 mg sublingual Tab [HMC]
|
Facility
|
IP
|
$10.82
|
|
|
Service Code
|
NDC 00071041813
|
| Hospital Charge Code |
3802946
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.28
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
nitroglycerin 0.4 mg sublingual Tab [HMC]
|
Facility
|
OP
|
$10.82
|
|
|
Service Code
|
NDC 58151031052
|
| Hospital Charge Code |
3802946
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$10.28 |
| Rate for Payer: Aetna Commercial |
$9.74
|
| Rate for Payer: Humana Medicare Advantage |
$4.54
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.33
|
| Rate for Payer: WPPA Medicare Advantage |
$6.49
|
|
|
nitroglycerin 0.4 mg sublingual Tab [HMC]
|
Facility
|
OP
|
$10.82
|
|
|
Service Code
|
NDC 00071041813
|
| Hospital Charge Code |
3802946
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$10.28 |
| Rate for Payer: Aetna Commercial |
$9.74
|
| Rate for Payer: Humana Medicare Advantage |
$4.54
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.33
|
| Rate for Payer: WPPA Medicare Advantage |
$6.49
|
|
|
nitroglycerin 10 mg/100 mL-D5W IV Sol [HMC]
|
Facility
|
OP
|
$49.56
|
|
|
Service Code
|
NDC 00409148302
|
| Hospital Charge Code |
3809461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.82 |
| Max. Negotiated Rate |
$47.08 |
| Rate for Payer: Aetna Commercial |
$44.60
|
| Rate for Payer: Humana Medicare Advantage |
$20.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$47.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.82
|
| Rate for Payer: WPPA Medicare Advantage |
$29.74
|
|
|
nitroglycerin 10 mg/100 mL-D5W IV Sol [HMC]
|
Facility
|
OP
|
$56.87
|
|
|
Service Code
|
NDC 00338104702
|
| Hospital Charge Code |
3809461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$54.03 |
| Rate for Payer: Aetna Commercial |
$51.18
|
| Rate for Payer: Humana Medicare Advantage |
$23.89
|
| Rate for Payer: UnitedHealthcare Commercial |
$54.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.75
|
| Rate for Payer: WPPA Medicare Advantage |
$34.12
|
|
|
nitroglycerin 10 mg/100 mL-D5W IV Sol [HMC]
|
Facility
|
IP
|
$49.56
|
|
|
Service Code
|
NDC 00409148302
|
| Hospital Charge Code |
3809461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.60 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$44.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$47.08
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
