|
Antithrombin III Activity QST
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
HCPCS 85300
|
| Hospital Charge Code |
3552491
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$66.50
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Antithrombin III Activity QST
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
HCPCS 85300
|
| Hospital Charge Code |
3552491
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$66.50 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$42.97
|
| Rate for Payer: Humana Medicare Advantage |
$29.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$66.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.85
|
| Rate for Payer: WPPA Medicare Advantage |
$42.00
|
|
|
antivenin (Crotalidae) polyvalent - Pow [HMC]
|
Facility
|
IP
|
$5,776.40
|
|
|
Service Code
|
HCPCS J0840
|
| Hospital Charge Code |
3809775
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$5,487.58 |
| Rate for Payer: Aetna Commercial |
$5,198.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,487.58
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
antivenin (Crotalidae) polyvalent - Pow [HMC]
|
Facility
|
OP
|
$5,776.40
|
|
|
Service Code
|
HCPCS J0840
|
| Hospital Charge Code |
3809775
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,826.52 |
| Max. Negotiated Rate |
$5,487.58 |
| Rate for Payer: Aetna Commercial |
$5,198.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2,436.16
|
| Rate for Payer: Humana Medicare Advantage |
$2,426.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,487.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,826.52
|
| Rate for Payer: WPPA Medicare Advantage |
$3,465.84
|
|
|
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC
|
Facility
|
IP
|
$24,653.52
|
|
|
Service Code
|
MSDRG 268
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$24,653.52 |
| Rate for Payer: UnitedHealthcare Medicaid |
$24,653.52
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC
|
Facility
|
IP
|
$15,122.52
|
|
|
Service Code
|
MSDRG 269
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$15,122.52 |
| Rate for Payer: UnitedHealthcare Medicaid |
$15,122.52
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
APAP/ASA/caffeine 250 mg-250 mg-65 mg Tab [HMC]
|
Facility
|
OP
|
$15.61
|
|
|
Service Code
|
NDC 00067203991
|
| Hospital Charge Code |
3808909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Aetna Commercial |
$14.05
|
| Rate for Payer: Humana Medicare Advantage |
$6.56
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.24
|
| Rate for Payer: WPPA Medicare Advantage |
$9.37
|
|
|
APAP/ASA/caffeine 250 mg-250 mg-65 mg Tab [HMC]
|
Facility
|
OP
|
$15.10
|
|
|
Service Code
|
NDC 00536132601
|
| Hospital Charge Code |
3808909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.04 |
| Max. Negotiated Rate |
$14.35 |
| Rate for Payer: Aetna Commercial |
$13.59
|
| Rate for Payer: Humana Medicare Advantage |
$6.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.04
|
| Rate for Payer: WPPA Medicare Advantage |
$9.06
|
|
|
APAP/ASA/caffeine 250 mg-250 mg-65 mg Tab [HMC]
|
Facility
|
IP
|
$15.10
|
|
|
Service Code
|
NDC 00536132601
|
| Hospital Charge Code |
3808909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.59 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$13.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
APAP/ASA/caffeine 250 mg-250 mg-65 mg Tab [HMC]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 70000002471
|
| Hospital Charge Code |
3808909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$13.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.25
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
APAP/ASA/caffeine 250 mg-250 mg-65 mg Tab [HMC]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 70000002471
|
| Hospital Charge Code |
3808909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$14.25 |
| Rate for Payer: Aetna Commercial |
$13.50
|
| Rate for Payer: Humana Medicare Advantage |
$6.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.00
|
| Rate for Payer: WPPA Medicare Advantage |
$9.00
|
|
|
APAP/ASA/caffeine 250 mg-250 mg-65 mg Tab [HMC]
|
Facility
|
IP
|
$15.61
|
|
|
Service Code
|
NDC 00067203991
|
| Hospital Charge Code |
3808909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.05 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$14.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.83
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [HMC]
|
Facility
|
OP
|
$9.81
|
|
|
Service Code
|
NDC 10702025350
|
| Hospital Charge Code |
3800391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$9.32 |
| Rate for Payer: Aetna Commercial |
$8.83
|
| Rate for Payer: Humana Medicare Advantage |
$4.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.92
|
| Rate for Payer: WPPA Medicare Advantage |
$5.89
|
|
|
APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [HMC]
|
Facility
|
OP
|
$10.06
|
|
|
Service Code
|
NDC 70010014901
|
| Hospital Charge Code |
3800391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$9.05
|
| Rate for Payer: Humana Medicare Advantage |
$4.23
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.02
|
| Rate for Payer: WPPA Medicare Advantage |
$6.04
|
|
|
APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [HMC]
|
Facility
|
OP
|
$10.06
|
|
|
Service Code
|
NDC 00527169501
|
| Hospital Charge Code |
3800391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$9.05
|
| Rate for Payer: Humana Medicare Advantage |
$4.23
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.02
|
| Rate for Payer: WPPA Medicare Advantage |
$6.04
|
|
|
APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [HMC]
|
Facility
|
IP
|
$10.06
|
|
|
Service Code
|
NDC 70010014901
|
| Hospital Charge Code |
3800391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.56
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [HMC]
|
Facility
|
IP
|
$10.06
|
|
|
Service Code
|
NDC 00527169501
|
| Hospital Charge Code |
3800391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.56
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [HMC]
|
Facility
|
IP
|
$10.06
|
|
|
Service Code
|
NDC 00603254421
|
| Hospital Charge Code |
3800391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.56
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [HMC]
|
Facility
|
IP
|
$9.81
|
|
|
Service Code
|
NDC 10702025350
|
| Hospital Charge Code |
3800391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.83 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.83
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.32
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [HMC]
|
Facility
|
OP
|
$10.06
|
|
|
Service Code
|
NDC 00603254421
|
| Hospital Charge Code |
3800391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$9.05
|
| Rate for Payer: Humana Medicare Advantage |
$4.23
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.02
|
| Rate for Payer: WPPA Medicare Advantage |
$6.04
|
|
|
Aphasia Assessment Charge
|
Facility
|
IP
|
$343.00
|
|
|
Service Code
|
HCPCS 96105 GN
|
| Hospital Charge Code |
4056105
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$308.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$308.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$325.85
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Aphasia Assessment Charge
|
Facility
|
OP
|
$343.00
|
|
|
Service Code
|
HCPCS 96105 GN
|
| Hospital Charge Code |
4056105
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$32.76 |
| Max. Negotiated Rate |
$325.85 |
| Rate for Payer: Aetna Commercial |
$308.70
|
| Rate for Payer: Humana Medicare Advantage |
$144.06
|
| Rate for Payer: UnitedHealthcare Commercial |
$325.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.76
|
| Rate for Payer: WPPA Medicare Advantage |
$205.80
|
|
|
apixaban 5 mg Tab [HMC]
|
Facility
|
IP
|
$28.78
|
|
|
Service Code
|
NDC 00003089421
|
| Hospital Charge Code |
3800091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$27.34
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
apixaban 5 mg Tab [HMC]
|
Facility
|
OP
|
$28.78
|
|
|
Service Code
|
NDC 00003089421
|
| Hospital Charge Code |
3800091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.51 |
| Max. Negotiated Rate |
$27.34 |
| Rate for Payer: Aetna Commercial |
$25.90
|
| Rate for Payer: Humana Medicare Advantage |
$12.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$27.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.51
|
| Rate for Payer: WPPA Medicare Advantage |
$17.27
|
|
|
Appendectomy
|
Facility
|
OP
|
$8,187.00
|
|
|
Service Code
|
HCPCS 44950
|
| Hospital Charge Code |
3150235
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,450.86 |
| Max. Negotiated Rate |
$7,777.65 |
| Rate for Payer: Aetna Commercial |
$7,368.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$5,906.48
|
| Rate for Payer: Humana Medicare Advantage |
$3,438.54
|
| Rate for Payer: UnitedHealthcare Commercial |
$7,777.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,450.86
|
| Rate for Payer: WPPA Medicare Advantage |
$4,912.20
|
|
