|
IP INITIAL ADMIT EXTENDED
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
CPT 99223
|
| Hospital Charge Code |
9899223
|
| Rate for Payer: Cash Price |
$450.00
|
|
|
IP INITIAL ADMIT INTERMEDIATE
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
CPT 99222
|
| Hospital Charge Code |
9899222
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$342.00
|
|
|
IP INITIAL ADMIT INTERMEDIATE
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
CPT 99222
|
| Hospital Charge Code |
9899222
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$173.53 |
| Max. Negotiated Rate |
$271.32 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$224.96
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$271.32
|
| Rate for Payer: Cash Price |
$342.00
|
| Rate for Payer: Cash Price |
$342.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$253.46
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
IP INITIAL CONSULT COMPLEX
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
CPT 99255
|
| Hospital Charge Code |
9899255
|
| Rate for Payer: Cash Price |
$432.00
|
|
|
IP INITIAL CONSULT COMPREHENSIVE
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
CPT 99254
|
| Hospital Charge Code |
9899254
|
| Rate for Payer: Cash Price |
$351.00
|
|
|
IP INITIAL CONSULT EXTENDED
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
CPT 99253
|
| Hospital Charge Code |
9899253
|
| Rate for Payer: Cash Price |
$270.00
|
|
|
IP INITIAL CONSULT INTERMEDIATE
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
CPT 99252
|
| Hospital Charge Code |
9899252
|
| Rate for Payer: Cash Price |
$216.00
|
|
|
IP INITIAL HOSP CARE BRIEF
|
Facility
|
IP
|
$260.00
|
|
|
Service Code
|
CPT 99221
|
| Hospital Charge Code |
4299221
|
| Rate for Payer: Cash Price |
$234.00
|
|
|
IP INITIAL HOSP CARE EXTENDED
|
Facility
|
IP
|
$471.00
|
|
|
Service Code
|
CPT 99223
|
| Hospital Charge Code |
4299223
|
| Rate for Payer: Cash Price |
$423.90
|
|
|
IP INITIAL HOSP CARE INTERMEDIATED
|
Facility
|
IP
|
$345.00
|
|
|
Service Code
|
CPT 99222
|
| Hospital Charge Code |
4299222
|
| Rate for Payer: Cash Price |
$310.50
|
|
|
IPRATR/ALBUT 0.5/3MG (DUO NEB) SOL 3ML
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS J7620
|
| Hospital Charge Code |
2676081
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$64.80
|
|
|
IPRATR/ALBUT 0.5/3MG (DUO NEB) SOL 3ML
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS J7620
|
| Hospital Charge Code |
2676081
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.92 |
| Max. Negotiated Rate |
$51.41 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$42.62
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$51.41
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$48.02
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$25.92
|
|
|
IPRATR/ALBUT (DUO NEB) SOL 60V EMP
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS J7620
|
| Hospital Charge Code |
2622873
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.92 |
| Max. Negotiated Rate |
$51.41 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$42.62
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$51.41
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$48.02
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$25.92
|
|
|
IPRATR/ALBUT (DUO NEB) SOL 60V EMP
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS J7620
|
| Hospital Charge Code |
2622873
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$64.80
|
|
|
IPRATRO/ALBUT(COMBIVENT RESPIMAT) 4G INH
|
Facility
|
IP
|
$1,104.00
|
|
|
Service Code
|
NDC 597002402
|
| Hospital Charge Code |
2697231
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$993.60
|
|
|
IPRATRO/ALBUT(COMBIVENT RESPIMAT) 4G INH
|
Facility
|
OP
|
$1,104.00
|
|
|
Service Code
|
NDC 597002402
|
| Hospital Charge Code |
2697231
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$397.44 |
| Max. Negotiated Rate |
$788.26 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$653.57
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$788.26
|
| Rate for Payer: Cash Price |
$993.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$736.37
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$397.44
|
|
|
IPRATROP/ALBUT 0.5MG/3MG NEB 3ML EMP 30
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
2623093
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.04 |
| Max. Negotiated Rate |
$27.85 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$23.09
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$27.85
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$14.04
|
|
|
IPRATROP/ALBUT 0.5MG/3MG NEB 3ML EMP 30
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
2623093
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$35.10
|
|
|
IPRATROP/ALBUT(COMBIVENT)14.7GM INH
|
Facility
|
IP
|
$659.00
|
|
|
Service Code
|
NDC 597001314
|
| Hospital Charge Code |
2654051
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$593.10
|
|
|
IPRATROP/ALBUT(COMBIVENT)14.7GM INH
|
Facility
|
OP
|
$659.00
|
|
|
Service Code
|
NDC 597001314
|
| Hospital Charge Code |
2654051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$237.24 |
| Max. Negotiated Rate |
$470.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$390.13
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$470.53
|
| Rate for Payer: Cash Price |
$593.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$439.55
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$237.24
|
|
|
IPRATROP(ATROVENT)0.5MG/2.5ML INH / NEB
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
2626442
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.04 |
| Max. Negotiated Rate |
$27.85 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$23.09
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$27.85
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$14.04
|
|
|
IPRATROP(ATROVENT)0.5MG/2.5ML INH / NEB
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
2626442
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$35.10
|
|
|
IPRATROP BR 0.06% 15ML NASAL SOL EMP
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
2624051
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$35.10
|
|
|
IPRATROP BR 0.06% 15ML NASAL SOL EMP
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
2624051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.04 |
| Max. Negotiated Rate |
$27.85 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$23.09
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$27.85
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$14.04
|
|
|
IPRATROP BR 0.5MG/2.5ML NEB EMP 60V
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
2623582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.04 |
| Max. Negotiated Rate |
$27.85 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$23.09
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$27.85
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$14.04
|
|
