|
Carbamazepine, Total QST
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
HCPCS 80156
|
| Hospital Charge Code |
3551435
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$154.85 |
| Rate for Payer: Aetna Commercial |
$146.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$91.63
|
| Rate for Payer: Humana Medicare Advantage |
$68.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$154.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.57
|
| Rate for Payer: WPPA Medicare Advantage |
$97.80
|
|
|
Carbamazepine, Total QST
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS 80156
|
| Hospital Charge Code |
3551435
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$146.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$146.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$154.85
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carbamide peroxide Otic 6.5% Sol [HMC]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
NDC 46122055705
|
| Hospital Charge Code |
3800415
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carbamide peroxide Otic 6.5% Sol [HMC]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
NDC 46122055705
|
| Hospital Charge Code |
3800415
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Humana Medicare Advantage |
$10.92
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.40
|
| Rate for Payer: WPPA Medicare Advantage |
$15.60
|
|
|
carbidopa-levodopa 10 mg-100 mg Tab [HMC]
|
Facility
|
IP
|
$7.32
|
|
|
Service Code
|
NDC 50228045701
|
| Hospital Charge Code |
3804644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.59 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carbidopa-levodopa 10 mg-100 mg Tab [HMC]
|
Facility
|
IP
|
$7.32
|
|
|
Service Code
|
NDC 00228253810
|
| Hospital Charge Code |
3804644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.59 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carbidopa-levodopa 10 mg-100 mg Tab [HMC]
|
Facility
|
OP
|
$7.32
|
|
|
Service Code
|
NDC 50228045701
|
| Hospital Charge Code |
3804644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.93 |
| Max. Negotiated Rate |
$6.95 |
| Rate for Payer: Aetna Commercial |
$6.59
|
| Rate for Payer: Humana Medicare Advantage |
$3.07
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.93
|
| Rate for Payer: WPPA Medicare Advantage |
$4.39
|
|
|
carbidopa-levodopa 10 mg-100 mg Tab [HMC]
|
Facility
|
IP
|
$7.32
|
|
|
Service Code
|
NDC 75907002201
|
| Hospital Charge Code |
3804644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.59 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carbidopa-levodopa 10 mg-100 mg Tab [HMC]
|
Facility
|
IP
|
$7.13
|
|
|
Service Code
|
NDC 62756051788
|
| Hospital Charge Code |
3804644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.42 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.77
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carbidopa-levodopa 10 mg-100 mg Tab [HMC]
|
Facility
|
OP
|
$7.32
|
|
|
Service Code
|
NDC 00228253810
|
| Hospital Charge Code |
3804644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.93 |
| Max. Negotiated Rate |
$6.95 |
| Rate for Payer: Aetna Commercial |
$6.59
|
| Rate for Payer: Humana Medicare Advantage |
$3.07
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.93
|
| Rate for Payer: WPPA Medicare Advantage |
$4.39
|
|
|
carbidopa-levodopa 10 mg-100 mg Tab [HMC]
|
Facility
|
OP
|
$7.32
|
|
|
Service Code
|
NDC 75907002201
|
| Hospital Charge Code |
3804644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.93 |
| Max. Negotiated Rate |
$6.95 |
| Rate for Payer: Aetna Commercial |
$6.59
|
| Rate for Payer: Humana Medicare Advantage |
$3.07
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.93
|
| Rate for Payer: WPPA Medicare Advantage |
$4.39
|
|
|
carbidopa-levodopa 10 mg-100 mg Tab [HMC]
|
Facility
|
OP
|
$7.13
|
|
|
Service Code
|
NDC 62756051788
|
| Hospital Charge Code |
3804644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$6.77 |
| Rate for Payer: Aetna Commercial |
$6.42
|
| Rate for Payer: Humana Medicare Advantage |
$2.99
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.85
|
| Rate for Payer: WPPA Medicare Advantage |
$4.28
|
|
|
carbidopa-levodopa 25 mg-100 mg Tab [HMC]
|
Facility
|
IP
|
$5.90
|
|
|
Service Code
|
NDC 00904750161
|
| Hospital Charge Code |
3806491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.31
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.61
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carbidopa-levodopa 25 mg-100 mg Tab [HMC]
|
Facility
|
OP
|
$7.46
|
|
|
Service Code
|
NDC 68084009301
|
| Hospital Charge Code |
3806491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$7.09 |
| Rate for Payer: Aetna Commercial |
$6.71
|
| Rate for Payer: Humana Medicare Advantage |
$3.13
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.98
|
| Rate for Payer: WPPA Medicare Advantage |
$4.48
|
|
|
carbidopa-levodopa 25 mg-100 mg Tab [HMC]
|
Facility
|
IP
|
$7.46
|
|
|
Service Code
|
NDC 60687066101
|
| Hospital Charge Code |
3806491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.09
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carbidopa-levodopa 25 mg-100 mg Tab [HMC]
|
Facility
|
OP
|
$5.68
|
|
|
Service Code
|
NDC 00904725761
|
| Hospital Charge Code |
3806491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna Commercial |
$5.11
|
| Rate for Payer: Humana Medicare Advantage |
$2.39
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.27
|
| Rate for Payer: WPPA Medicare Advantage |
$3.41
|
|
|
carbidopa-levodopa 25 mg-100 mg Tab [HMC]
|
Facility
|
OP
|
$5.90
|
|
|
Service Code
|
NDC 00904750161
|
| Hospital Charge Code |
3806491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$5.61 |
| Rate for Payer: Aetna Commercial |
$5.31
|
| Rate for Payer: Humana Medicare Advantage |
$2.48
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.36
|
| Rate for Payer: WPPA Medicare Advantage |
$3.54
|
|
|
carbidopa-levodopa 25 mg-100 mg Tab [HMC]
|
Facility
|
IP
|
$7.46
|
|
|
Service Code
|
NDC 68084009301
|
| Hospital Charge Code |
3806491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.09
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carbidopa-levodopa 25 mg-100 mg Tab [HMC]
|
Facility
|
IP
|
$5.68
|
|
|
Service Code
|
NDC 00904725761
|
| Hospital Charge Code |
3806491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.11 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.11
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.40
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carbidopa-levodopa 25 mg-100 mg Tab [HMC]
|
Facility
|
OP
|
$7.46
|
|
|
Service Code
|
NDC 60687066101
|
| Hospital Charge Code |
3806491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$7.09 |
| Rate for Payer: Aetna Commercial |
$6.71
|
| Rate for Payer: Humana Medicare Advantage |
$3.13
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.98
|
| Rate for Payer: WPPA Medicare Advantage |
$4.48
|
|
|
carbidopa-levodopa 25 mg-250 mg Tab [HMC]
|
Facility
|
IP
|
$8.33
|
|
|
Service Code
|
NDC 00228254010
|
| Hospital Charge Code |
3804651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.91
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
carbidopa-levodopa 25 mg-250 mg Tab [HMC]
|
Facility
|
OP
|
$7.84
|
|
|
Service Code
|
NDC 68084009401
|
| Hospital Charge Code |
3804651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$7.45 |
| Rate for Payer: Aetna Commercial |
$7.06
|
| Rate for Payer: Humana Medicare Advantage |
$3.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.14
|
| Rate for Payer: WPPA Medicare Advantage |
$4.70
|
|
|
carbidopa-levodopa 25 mg-250 mg Tab [HMC]
|
Facility
|
OP
|
$8.33
|
|
|
Service Code
|
NDC 00228254010
|
| Hospital Charge Code |
3804651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$7.91 |
| Rate for Payer: Aetna Commercial |
$7.50
|
| Rate for Payer: Humana Medicare Advantage |
$3.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.33
|
| Rate for Payer: WPPA Medicare Advantage |
$5.00
|
|
|
carbidopa-levodopa 25 mg-250 mg Tab [HMC]
|
Facility
|
OP
|
$6.31
|
|
|
Service Code
|
NDC 60687083601
|
| Hospital Charge Code |
3804651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$5.99 |
| Rate for Payer: Aetna Commercial |
$5.68
|
| Rate for Payer: Humana Medicare Advantage |
$2.65
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.52
|
| Rate for Payer: WPPA Medicare Advantage |
$3.79
|
|
|
carbidopa-levodopa 25 mg-250 mg Tab [HMC]
|
Facility
|
IP
|
$6.31
|
|
|
Service Code
|
NDC 60687083601
|
| Hospital Charge Code |
3804651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.68 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.68
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.99
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
