|
albuterol 0.083% Inh Sol 3 mL [HMC]
|
Facility
|
IP
|
$12.66
|
|
|
Service Code
|
NDC 65862085825
|
| Hospital Charge Code |
3804362
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.39 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$11.39
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.03
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
albuterol 0.083% Inh Sol 3 mL [HMC]
|
Facility
|
OP
|
$11.60
|
|
|
Service Code
|
HCPCS J7613
|
| Hospital Charge Code |
3804362
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$11.02 |
| Rate for Payer: Aetna Commercial |
$10.44
|
| Rate for Payer: Aetna Commercial |
$11.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.31
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.31
|
| Rate for Payer: Humana Medicare Advantage |
$5.32
|
| Rate for Payer: Humana Medicare Advantage |
$4.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.03
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.06
|
| Rate for Payer: WPPA Medicare Advantage |
$7.60
|
| Rate for Payer: WPPA Medicare Advantage |
$6.96
|
|
|
albuterol CFC free 90 mcg/inh Inh Aer w/Adapt [HMC]
|
Facility
|
IP
|
$109.93
|
|
|
Service Code
|
NDC 68180096301
|
| Hospital Charge Code |
3804975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.94 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$98.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$104.43
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
albuterol CFC free 90 mcg/inh Inh Aer w/Adapt [HMC]
|
Facility
|
OP
|
$128.75
|
|
|
Service Code
|
NDC 59310057922
|
| Hospital Charge Code |
3804975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.50 |
| Max. Negotiated Rate |
$122.31 |
| Rate for Payer: Aetna Commercial |
$115.88
|
| Rate for Payer: Humana Medicare Advantage |
$54.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$122.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.50
|
| Rate for Payer: WPPA Medicare Advantage |
$77.25
|
|
|
albuterol CFC free 90 mcg/inh Inh Aer w/Adapt [HMC]
|
Facility
|
OP
|
$109.93
|
|
|
Service Code
|
NDC 68180096301
|
| Hospital Charge Code |
3804975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.97 |
| Max. Negotiated Rate |
$104.43 |
| Rate for Payer: Aetna Commercial |
$98.94
|
| Rate for Payer: Humana Medicare Advantage |
$46.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$104.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.97
|
| Rate for Payer: WPPA Medicare Advantage |
$65.96
|
|
|
albuterol CFC free 90 mcg/inh Inh Aer w/Adapt [HMC]
|
Facility
|
IP
|
$128.75
|
|
|
Service Code
|
NDC 59310057922
|
| Hospital Charge Code |
3804975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$115.88 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$115.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$122.31
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
albuterol-ipratropium 100 mcg-20 mcg/inh Aer [HMC]
|
Facility
|
OP
|
$812.73
|
|
|
Service Code
|
NDC 00597002402
|
| Hospital Charge Code |
3800128
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$325.09 |
| Max. Negotiated Rate |
$772.09 |
| Rate for Payer: Aetna Commercial |
$731.46
|
| Rate for Payer: Humana Medicare Advantage |
$341.35
|
| Rate for Payer: UnitedHealthcare Commercial |
$772.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$325.09
|
| Rate for Payer: WPPA Medicare Advantage |
$487.64
|
|
|
albuterol-ipratropium 100 mcg-20 mcg/inh Aer [HMC]
|
Facility
|
IP
|
$812.73
|
|
|
Service Code
|
NDC 00597002402
|
| Hospital Charge Code |
3800128
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$731.46 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$731.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$772.09
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Sol [HMC]
|
Facility
|
OP
|
$14.38
|
|
|
Service Code
|
NDC 69097017353
|
| Hospital Charge Code |
3808983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.75 |
| Max. Negotiated Rate |
$13.66 |
| Rate for Payer: Aetna Commercial |
$12.94
|
| Rate for Payer: Humana Medicare Advantage |
$6.04
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.75
|
| Rate for Payer: WPPA Medicare Advantage |
$8.63
|
|
|
albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Sol [HMC]
|
Facility
|
OP
|
$14.21
|
|
|
Service Code
|
NDC 69097017364
|
| Hospital Charge Code |
3808983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.68 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna Commercial |
$12.79
|
| Rate for Payer: Humana Medicare Advantage |
$5.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.68
|
| Rate for Payer: WPPA Medicare Advantage |
$8.53
|
|
|
albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Sol [HMC]
|
Facility
|
OP
|
$14.21
|
|
|
Service Code
|
NDC 00487020160
|
| Hospital Charge Code |
3808983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.68 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna Commercial |
$12.79
|
| Rate for Payer: Humana Medicare Advantage |
$5.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.68
|
| Rate for Payer: WPPA Medicare Advantage |
$8.53
|
|
|
albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Sol [HMC]
|
Facility
|
IP
|
$14.38
|
|
|
Service Code
|
NDC 69097017353
|
| Hospital Charge Code |
3808983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.94 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$12.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.66
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Sol [HMC]
|
Facility
|
IP
|
$14.21
|
|
|
Service Code
|
NDC 69097017364
|
| Hospital Charge Code |
3808983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.79 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$12.79
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.50
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Sol [HMC]
|
Facility
|
IP
|
$14.21
|
|
|
Service Code
|
NDC 00487020160
|
| Hospital Charge Code |
3808983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$12.79 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$12.79
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.50
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Sol [HMC]
|
Facility
|
IP
|
$14.60
|
|
|
Service Code
|
HCPCS J7620
|
| Hospital Charge Code |
3808983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.14 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$13.14
|
| Rate for Payer: Aetna Commercial |
$12.79
|
| Rate for Payer: Aetna Commercial |
$12.98
|
| Rate for Payer: Aetna Commercial |
$10.40
|
| Rate for Payer: Aetna Commercial |
$12.94
|
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.65
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.66
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Sol [HMC]
|
Facility
|
OP
|
$14.21
|
|
|
Service Code
|
HCPCS J7620
|
| Hospital Charge Code |
3808983
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna Commercial |
$12.79
|
| Rate for Payer: Aetna Commercial |
$13.14
|
| Rate for Payer: Aetna Commercial |
$10.40
|
| Rate for Payer: Aetna Commercial |
$12.98
|
| Rate for Payer: Aetna Commercial |
$12.94
|
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.49
|
| Rate for Payer: Humana Medicare Advantage |
$6.13
|
| Rate for Payer: Humana Medicare Advantage |
$4.86
|
| Rate for Payer: Humana Medicare Advantage |
$6.06
|
| Rate for Payer: Humana Medicare Advantage |
$6.04
|
| Rate for Payer: Humana Medicare Advantage |
$6.04
|
| Rate for Payer: Humana Medicare Advantage |
$5.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.65
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.66
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.20
|
| Rate for Payer: WPPA Medicare Advantage |
$8.76
|
| Rate for Payer: WPPA Medicare Advantage |
$6.94
|
| Rate for Payer: WPPA Medicare Advantage |
$8.53
|
| Rate for Payer: WPPA Medicare Advantage |
$8.62
|
| Rate for Payer: WPPA Medicare Advantage |
$8.63
|
| Rate for Payer: WPPA Medicare Advantage |
$8.65
|
|
|
albuterol-ipratropium Inh Aer w/Adapt [HMC]
|
Facility
|
IP
|
$344.47
|
|
|
Service Code
|
NDC 00597001314
|
| Hospital Charge Code |
3805576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$310.02 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$310.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$327.25
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
albuterol-ipratropium Inh Aer w/Adapt [HMC]
|
Facility
|
OP
|
$344.47
|
|
|
Service Code
|
NDC 00597001314
|
| Hospital Charge Code |
3805576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$137.79 |
| Max. Negotiated Rate |
$327.25 |
| Rate for Payer: Aetna Commercial |
$310.02
|
| Rate for Payer: Humana Medicare Advantage |
$144.68
|
| Rate for Payer: UnitedHealthcare Commercial |
$327.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$137.79
|
| Rate for Payer: WPPA Medicare Advantage |
$206.68
|
|
|
ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA
|
Facility
|
IP
|
$2,160.36
|
|
|
Service Code
|
MSDRG 894
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$2,160.36 |
| Rate for Payer: UnitedHealthcare Medicaid |
$2,160.36
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC
|
Facility
|
IP
|
$6,767.01
|
|
|
Service Code
|
MSDRG 896
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$6,767.01 |
| Rate for Payer: UnitedHealthcare Medicaid |
$6,767.01
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC
|
Facility
|
IP
|
$3,462.93
|
|
|
Service Code
|
MSDRG 897
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$3,462.93 |
| Rate for Payer: UnitedHealthcare Medicaid |
$3,462.93
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY
|
Facility
|
IP
|
$5,496.21
|
|
|
Service Code
|
MSDRG 895
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$5,496.21 |
| Rate for Payer: UnitedHealthcare Medicaid |
$5,496.21
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Alcohol Level
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
HCPCS 80320
|
| Hospital Charge Code |
3550032
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$131.10 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$60.63
|
| Rate for Payer: Humana Medicare Advantage |
$57.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$131.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.50
|
| Rate for Payer: WPPA Medicare Advantage |
$82.80
|
|
|
Alcohol Level
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
HCPCS 80320
|
| Hospital Charge Code |
3550032
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$124.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$131.10
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Aldolase QST
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
HCPCS 82085
|
| Hospital Charge Code |
3552085
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$60.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
