|
Appendectomy
|
Facility
|
IP
|
$8,187.00
|
|
|
Service Code
|
HCPCS 44950
|
| Hospital Charge Code |
3150235
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$7,777.65 |
| Rate for Payer: Aetna Commercial |
$7,368.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$7,777.65
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
APPENDIX PROCEDURES WITH CC
|
Facility
|
IP
|
$4,543.11
|
|
|
Service Code
|
MSDRG 398
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,543.11 |
| Rate for Payer: UnitedHealthcare Medicaid |
$4,543.11
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
APPENDIX PROCEDURES WITH MCC
|
Facility
|
IP
|
$9,054.45
|
|
|
Service Code
|
MSDRG 397
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$9,054.45 |
| Rate for Payer: UnitedHealthcare Medicaid |
$9,054.45
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
APPENDIX PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$3,431.16
|
|
|
Service Code
|
MSDRG 399
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$3,431.16 |
| Rate for Payer: UnitedHealthcare Medicaid |
$3,431.16
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
aprepitant 40 mg oral capsule [HMC]
|
Facility
|
OP
|
$114.94
|
|
|
Service Code
|
HCPCS J8501
|
| Hospital Charge Code |
3851320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$109.19 |
| Rate for Payer: Aetna Commercial |
$103.45
|
| Rate for Payer: Aetna Commercial |
$127.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$4.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$4.50
|
| Rate for Payer: Humana Medicare Advantage |
$59.63
|
| Rate for Payer: Humana Medicare Advantage |
$48.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$109.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$134.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$45.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$56.79
|
| Rate for Payer: WPPA Medicare Advantage |
$85.19
|
| Rate for Payer: WPPA Medicare Advantage |
$68.96
|
|
|
aprepitant 40 mg oral capsule [HMC]
|
Facility
|
IP
|
$114.94
|
|
|
Service Code
|
HCPCS J8501
|
| Hospital Charge Code |
3851320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.45 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$103.45
|
| Rate for Payer: Aetna Commercial |
$127.78
|
| Rate for Payer: UnitedHealthcare Commercial |
$109.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$134.88
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Aquaporin 4 Ab (NMO IgG), ELISA QST
|
Facility
|
OP
|
$980.00
|
|
|
Service Code
|
HCPCS 86052
|
| Hospital Charge Code |
3556052
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.83 |
| Max. Negotiated Rate |
$931.00 |
| Rate for Payer: Aetna Commercial |
$882.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$22.59
|
| Rate for Payer: Humana Medicare Advantage |
$411.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$931.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.83
|
| Rate for Payer: WPPA Medicare Advantage |
$588.00
|
|
|
Aquaporin 4 Ab (NMO IgG), ELISA QST
|
Facility
|
IP
|
$980.00
|
|
|
Service Code
|
HCPCS 86052
|
| Hospital Charge Code |
3556052
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$882.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$882.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$931.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
arformoterol 15 mcg/2 mL Inh Sol [HMC]
|
Facility
|
OP
|
$37.35
|
|
|
Service Code
|
HCPCS J7605
|
| Hospital Charge Code |
3800027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$35.48 |
| Rate for Payer: Aetna Commercial |
$33.62
|
| Rate for Payer: Aetna Commercial |
$37.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2.38
|
| Rate for Payer: Humana Medicare Advantage |
$17.60
|
| Rate for Payer: Humana Medicare Advantage |
$15.69
|
| Rate for Payer: UnitedHealthcare Commercial |
$39.81
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.76
|
| Rate for Payer: WPPA Medicare Advantage |
$25.15
|
| Rate for Payer: WPPA Medicare Advantage |
$22.41
|
|
|
arformoterol 15 mcg/2 mL Inh Sol [HMC]
|
Facility
|
IP
|
$37.35
|
|
|
Service Code
|
NDC 70748017530
|
| Hospital Charge Code |
3800027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.62 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$33.62
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.48
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
arformoterol 15 mcg/2 mL Inh Sol [HMC]
|
Facility
|
IP
|
$41.91
|
|
|
Service Code
|
HCPCS J7605
|
| Hospital Charge Code |
3800027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.72 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$37.72
|
| Rate for Payer: Aetna Commercial |
$33.62
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.48
|
| Rate for Payer: UnitedHealthcare Commercial |
$39.81
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
arformoterol 15 mcg/2 mL Inh Sol [HMC]
|
Facility
|
OP
|
$37.35
|
|
|
Service Code
|
NDC 70748017530
|
| Hospital Charge Code |
3800027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.94 |
| Max. Negotiated Rate |
$35.48 |
| Rate for Payer: Aetna Commercial |
$33.62
|
| Rate for Payer: Humana Medicare Advantage |
$15.69
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.94
|
| Rate for Payer: WPPA Medicare Advantage |
$22.41
|
|
|
ARIPiprazole 15 mg Tab [HMC]
|
Facility
|
IP
|
$37.11
|
|
|
Service Code
|
NDC 13668021930
|
| Hospital Charge Code |
3800433
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$33.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.25
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ARIPiprazole 15 mg Tab [HMC]
|
Facility
|
OP
|
$37.11
|
|
|
Service Code
|
NDC 13668021930
|
| Hospital Charge Code |
3800433
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$35.25 |
| Rate for Payer: Aetna Commercial |
$33.40
|
| Rate for Payer: Humana Medicare Advantage |
$15.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.84
|
| Rate for Payer: WPPA Medicare Advantage |
$22.27
|
|
|
ARIPiprazole 2 mg oral tablet [HMC]
|
Facility
|
IP
|
$37.08
|
|
|
Service Code
|
NDC 65162089603
|
| Hospital Charge Code |
3800380
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.37 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$33.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.23
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ARIPiprazole 2 mg oral tablet [HMC]
|
Facility
|
OP
|
$35.59
|
|
|
Service Code
|
NDC 50268008712
|
| Hospital Charge Code |
3800380
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.24 |
| Max. Negotiated Rate |
$33.81 |
| Rate for Payer: Aetna Commercial |
$32.03
|
| Rate for Payer: Humana Medicare Advantage |
$14.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.24
|
| Rate for Payer: WPPA Medicare Advantage |
$21.35
|
|
|
ARIPiprazole 2 mg oral tablet [HMC]
|
Facility
|
IP
|
$35.59
|
|
|
Service Code
|
NDC 50268008712
|
| Hospital Charge Code |
3800380
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.03 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$32.03
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.81
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ARIPiprazole 2 mg oral tablet [HMC]
|
Facility
|
OP
|
$28.35
|
|
|
Service Code
|
NDC 59148000613
|
| Hospital Charge Code |
3800380
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.34 |
| Max. Negotiated Rate |
$26.93 |
| Rate for Payer: Aetna Commercial |
$25.52
|
| Rate for Payer: Humana Medicare Advantage |
$11.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.34
|
| Rate for Payer: WPPA Medicare Advantage |
$17.01
|
|
|
ARIPiprazole 2 mg oral tablet [HMC]
|
Facility
|
IP
|
$28.35
|
|
|
Service Code
|
NDC 59148000613
|
| Hospital Charge Code |
3800380
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.52 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.93
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ARIPiprazole 2 mg oral tablet [HMC]
|
Facility
|
OP
|
$37.08
|
|
|
Service Code
|
NDC 65162089603
|
| Hospital Charge Code |
3800380
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.83 |
| Max. Negotiated Rate |
$35.23 |
| Rate for Payer: Aetna Commercial |
$33.37
|
| Rate for Payer: Humana Medicare Advantage |
$15.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.83
|
| Rate for Payer: WPPA Medicare Advantage |
$22.25
|
|
|
ARIPiprazole 5 mg Tab [HMC]
|
Facility
|
OP
|
$37.08
|
|
|
Service Code
|
NDC 65162089703
|
| Hospital Charge Code |
3800233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.83 |
| Max. Negotiated Rate |
$35.23 |
| Rate for Payer: Aetna Commercial |
$33.37
|
| Rate for Payer: Humana Medicare Advantage |
$15.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.83
|
| Rate for Payer: WPPA Medicare Advantage |
$22.25
|
|
|
ARIPiprazole 5 mg Tab [HMC]
|
Facility
|
IP
|
$28.35
|
|
|
Service Code
|
NDC 59148000713
|
| Hospital Charge Code |
3800233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.52 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.93
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ARIPiprazole 5 mg Tab [HMC]
|
Facility
|
OP
|
$26.60
|
|
|
Service Code
|
NDC 00904736761
|
| Hospital Charge Code |
3800233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.64 |
| Max. Negotiated Rate |
$25.27 |
| Rate for Payer: Aetna Commercial |
$23.94
|
| Rate for Payer: Humana Medicare Advantage |
$11.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$25.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.64
|
| Rate for Payer: WPPA Medicare Advantage |
$15.96
|
|
|
ARIPiprazole 5 mg Tab [HMC]
|
Facility
|
OP
|
$28.35
|
|
|
Service Code
|
NDC 59148000713
|
| Hospital Charge Code |
3800233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.34 |
| Max. Negotiated Rate |
$26.93 |
| Rate for Payer: Aetna Commercial |
$25.52
|
| Rate for Payer: Humana Medicare Advantage |
$11.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.34
|
| Rate for Payer: WPPA Medicare Advantage |
$17.01
|
|
|
ARIPiprazole 5 mg Tab [HMC]
|
Facility
|
IP
|
$37.08
|
|
|
Service Code
|
NDC 65162089703
|
| Hospital Charge Code |
3800233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.37 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$33.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.23
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
