|
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC
|
Facility
|
IP
|
$2,478.06
|
|
|
Service Code
|
MSDRG 192
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$2,478.06 |
| Rate for Payer: UnitedHealthcare Medicaid |
$2,478.06
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
cilostazol 100 mg Tab [HMC]
|
Facility
|
OP
|
$10.47
|
|
|
Service Code
|
NDC 60505252201
|
| Hospital Charge Code |
3809320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$9.95 |
| Rate for Payer: Aetna Commercial |
$9.42
|
| Rate for Payer: Humana Medicare Advantage |
$4.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.19
|
| Rate for Payer: WPPA Medicare Advantage |
$6.28
|
|
|
cilostazol 100 mg Tab [HMC]
|
Facility
|
IP
|
$10.47
|
|
|
Service Code
|
NDC 00093206406
|
| Hospital Charge Code |
3809320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.42 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
cilostazol 100 mg Tab [HMC]
|
Facility
|
IP
|
$11.75
|
|
|
Service Code
|
NDC 50268017715
|
| Hospital Charge Code |
3809320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.57 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.16
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
cilostazol 100 mg Tab [HMC]
|
Facility
|
OP
|
$11.75
|
|
|
Service Code
|
NDC 50268017715
|
| Hospital Charge Code |
3809320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$11.16 |
| Rate for Payer: Aetna Commercial |
$10.57
|
| Rate for Payer: Humana Medicare Advantage |
$4.93
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.70
|
| Rate for Payer: WPPA Medicare Advantage |
$7.05
|
|
|
cilostazol 100 mg Tab [HMC]
|
Facility
|
IP
|
$10.47
|
|
|
Service Code
|
NDC 60505252201
|
| Hospital Charge Code |
3809320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.42 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
cilostazol 100 mg Tab [HMC]
|
Facility
|
OP
|
$10.47
|
|
|
Service Code
|
NDC 00093206406
|
| Hospital Charge Code |
3809320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$9.95 |
| Rate for Payer: Aetna Commercial |
$9.42
|
| Rate for Payer: Humana Medicare Advantage |
$4.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.19
|
| Rate for Payer: WPPA Medicare Advantage |
$6.28
|
|
|
ciprofloxacin 400 mg/200 mL-5% Sol [HMC]
|
Facility
|
IP
|
$43.55
|
|
|
Service Code
|
HCPCS J0744
|
| Hospital Charge Code |
3808751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$39.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.37
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ciprofloxacin 400 mg/200 mL-5% Sol [HMC]
|
Facility
|
OP
|
$43.55
|
|
|
Service Code
|
HCPCS J0744
|
| Hospital Charge Code |
3808751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$41.37 |
| Rate for Payer: Aetna Commercial |
$39.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2.81
|
| Rate for Payer: Humana Medicare Advantage |
$18.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.00
|
| Rate for Payer: WPPA Medicare Advantage |
$26.13
|
|
|
ciprofloxacin 400 mg/200 mL IV Sol [HMC]
|
Facility
|
OP
|
$36.69
|
|
|
Service Code
|
HCPCS J0744
|
| Hospital Charge Code |
3808751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$34.86 |
| Rate for Payer: Aetna Commercial |
$33.02
|
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Commercial |
$39.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2.81
|
| Rate for Payer: Humana Medicare Advantage |
$18.29
|
| Rate for Payer: Humana Medicare Advantage |
$15.12
|
| Rate for Payer: Humana Medicare Advantage |
$15.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.00
|
| Rate for Payer: WPPA Medicare Advantage |
$22.01
|
| Rate for Payer: WPPA Medicare Advantage |
$21.60
|
| Rate for Payer: WPPA Medicare Advantage |
$26.13
|
|
|
ciprofloxacin 400 mg/200 mL IV Sol [HMC]
|
Facility
|
IP
|
$36.69
|
|
|
Service Code
|
HCPCS J0744
|
| Hospital Charge Code |
3808751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.02 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$33.02
|
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Commercial |
$39.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.37
|
| 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
|
|
|
ciprofloxacin 500 mg Tab [HMC]
|
Facility
|
OP
|
$14.53
|
|
|
Service Code
|
NDC 68084007001
|
| Hospital Charge Code |
3805931
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.81 |
| Max. Negotiated Rate |
$13.80 |
| Rate for Payer: Aetna Commercial |
$13.08
|
| Rate for Payer: Humana Medicare Advantage |
$6.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.81
|
| Rate for Payer: WPPA Medicare Advantage |
$8.72
|
|
|
ciprofloxacin 500 mg Tab [HMC]
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
NDC 00904708361
|
| Hospital Charge Code |
3805931
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.44 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.74
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ciprofloxacin 500 mg Tab [HMC]
|
Facility
|
IP
|
$18.42
|
|
|
Service Code
|
NDC 00143992801
|
| Hospital Charge Code |
3805931
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.58 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$16.58
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.50
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ciprofloxacin 500 mg Tab [HMC]
|
Facility
|
OP
|
$6.31
|
|
|
Service Code
|
NDC 60687086001
|
| Hospital Charge Code |
3805931
|
|
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
|
|
|
ciprofloxacin 500 mg Tab [HMC]
|
Facility
|
IP
|
$6.31
|
|
|
Service Code
|
NDC 60687086001
|
| Hospital Charge Code |
3805931
|
|
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
|
|
|
ciprofloxacin 500 mg Tab [HMC]
|
Facility
|
IP
|
$14.53
|
|
|
Service Code
|
NDC 68084007001
|
| Hospital Charge Code |
3805931
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.08 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$13.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ciprofloxacin 500 mg Tab [HMC]
|
Facility
|
OP
|
$18.42
|
|
|
Service Code
|
NDC 00143992801
|
| Hospital Charge Code |
3805931
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.37 |
| Max. Negotiated Rate |
$17.50 |
| Rate for Payer: Aetna Commercial |
$16.58
|
| Rate for Payer: Humana Medicare Advantage |
$7.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.37
|
| Rate for Payer: WPPA Medicare Advantage |
$11.05
|
|
|
ciprofloxacin 500 mg Tab [HMC]
|
Facility
|
OP
|
$6.04
|
|
|
Service Code
|
NDC 00904708361
|
| Hospital Charge Code |
3805931
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.44
|
| Rate for Payer: Humana Medicare Advantage |
$2.54
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.42
|
| Rate for Payer: WPPA Medicare Advantage |
$3.62
|
|
|
ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp 7.5 mL [HMC]
|
Facility
|
IP
|
$2,345.61
|
|
|
Service Code
|
NDC 00065853302
|
| Hospital Charge Code |
3800322
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$2,228.33 |
| Rate for Payer: Aetna Commercial |
$2,111.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,228.33
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp 7.5 mL [HMC]
|
Facility
|
OP
|
$2,345.61
|
|
|
Service Code
|
NDC 00065853302
|
| Hospital Charge Code |
3800322
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$938.24 |
| Max. Negotiated Rate |
$2,228.33 |
| Rate for Payer: Aetna Commercial |
$2,111.05
|
| Rate for Payer: Humana Medicare Advantage |
$985.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,228.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$938.24
|
| Rate for Payer: WPPA Medicare Advantage |
$1,407.37
|
|
|
ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [HMC]
|
Facility
|
IP
|
$1,150.56
|
|
|
Service Code
|
NDC 43598032675
|
| Hospital Charge Code |
3800322
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,035.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$1,035.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,093.03
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [HMC]
|
Facility
|
OP
|
$1,150.56
|
|
|
Service Code
|
NDC 43598032675
|
| Hospital Charge Code |
3800322
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$460.22 |
| Max. Negotiated Rate |
$1,093.03 |
| Rate for Payer: Aetna Commercial |
$1,035.50
|
| Rate for Payer: Humana Medicare Advantage |
$483.24
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,093.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$460.22
|
| Rate for Payer: WPPA Medicare Advantage |
$690.34
|
|
|
ciprofloxacin Ophth 0.3% Sol [HMC]
|
Facility
|
IP
|
$45.20
|
|
|
Service Code
|
NDC 61314065605
|
| Hospital Charge Code |
3800187
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.68 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$40.68
|
| Rate for Payer: UnitedHealthcare Commercial |
$42.94
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ciprofloxacin Ophth 0.3% Sol [HMC]
|
Facility
|
OP
|
$45.20
|
|
|
Service Code
|
NDC 69315030805
|
| Hospital Charge Code |
3800187
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.08 |
| Max. Negotiated Rate |
$42.94 |
| Rate for Payer: Aetna Commercial |
$40.68
|
| Rate for Payer: Humana Medicare Advantage |
$18.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$42.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.08
|
| Rate for Payer: WPPA Medicare Advantage |
$27.12
|
|
