|
Dextrose 10% in Water IV Sol 250 mL [HMC]
|
Facility
|
OP
|
$39.68
|
|
|
Service Code
|
NDC 00990793002
|
| Hospital Charge Code |
3254928
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.87 |
| Max. Negotiated Rate |
$37.70 |
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: Humana Medicare Advantage |
$16.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.87
|
| Rate for Payer: WPPA Medicare Advantage |
$23.81
|
|
|
Dextrose 10% in Water IV Sol 250 mL [HMC]
|
Facility
|
OP
|
$35.83
|
|
|
Service Code
|
NDC 00264752020
|
| Hospital Charge Code |
3254928
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.33 |
| Max. Negotiated Rate |
$34.04 |
| Rate for Payer: Aetna Commercial |
$32.25
|
| Rate for Payer: Humana Medicare Advantage |
$15.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.33
|
| Rate for Payer: WPPA Medicare Advantage |
$21.50
|
|
|
Dextrose 10% in Water IV Sol 250 mL [HMC]
|
Facility
|
IP
|
$35.83
|
|
|
Service Code
|
NDC 00264752020
|
| Hospital Charge Code |
3254928
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.25 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$32.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.04
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Dextrose 10% in Water IV Sol 250 mL [HMC]
|
Facility
|
IP
|
$39.68
|
|
|
Service Code
|
NDC 00990793002
|
| Hospital Charge Code |
3254928
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.71 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Dextrose 5% in Lactated Ringers 1000 mL Inj Sol [HMC]
|
Facility
|
OP
|
$39.68
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
3253916
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$37.70 |
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$9.39
|
| Rate for Payer: Humana Medicare Advantage |
$16.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.25
|
| Rate for Payer: WPPA Medicare Advantage |
$23.81
|
|
|
Dextrose 5% in Lactated Ringers 1000 mL Inj Sol [HMC]
|
Facility
|
IP
|
$39.68
|
|
|
Service Code
|
HCPCS J7121
|
| Hospital Charge Code |
3253916
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.71 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Dextrose 5% in Water intravenous solution 100 ml [HMC]
|
Facility
|
OP
|
$35.96
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
3255390
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$34.16 |
| Rate for Payer: Aetna Commercial |
$32.36
|
| Rate for Payer: Aetna Commercial |
$23.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2.32
|
| Rate for Payer: Humana Medicare Advantage |
$15.10
|
| Rate for Payer: Humana Medicare Advantage |
$10.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.77
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.75
|
| Rate for Payer: WPPA Medicare Advantage |
$21.58
|
| Rate for Payer: WPPA Medicare Advantage |
$15.64
|
|
|
Dextrose 5% in Water intravenous solution 100 ml [HMC]
|
Facility
|
IP
|
$26.07
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
3255390
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.46 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$23.46
|
| Rate for Payer: Aetna Commercial |
$32.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.77
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Dextrose 5% in Water IV Sol 1000 mL [HMC]
|
Facility
|
OP
|
$39.68
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
3250128
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$37.70 |
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$4.63
|
| Rate for Payer: Humana Medicare Advantage |
$16.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.94
|
| Rate for Payer: WPPA Medicare Advantage |
$23.81
|
|
|
Dextrose 5% in Water IV Sol 1000 mL [HMC]
|
Facility
|
IP
|
$39.68
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
3250128
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.71 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Dextrose 5% in Water IV Sol 250 mL [HMC]
|
Facility
|
IP
|
$30.18
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
3256901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.16 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$27.16
|
| Rate for Payer: Aetna Commercial |
$35.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.88
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Dextrose 5% in Water IV Sol 250 mL [HMC]
|
Facility
|
OP
|
$30.18
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
3256901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$28.67 |
| Rate for Payer: Aetna Commercial |
$27.16
|
| Rate for Payer: Aetna Commercial |
$35.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2.32
|
| Rate for Payer: Humana Medicare Advantage |
$12.68
|
| Rate for Payer: Humana Medicare Advantage |
$16.75
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.75
|
| Rate for Payer: WPPA Medicare Advantage |
$18.11
|
| Rate for Payer: WPPA Medicare Advantage |
$23.92
|
|
|
Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [HMC]
|
Facility
|
IP
|
$39.68
|
|
|
Service Code
|
NDC 00409792609
|
| Hospital Charge Code |
3253932
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.71 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [HMC]
|
Facility
|
OP
|
$39.68
|
|
|
Service Code
|
NDC 00990792609
|
| Hospital Charge Code |
3253932
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.87 |
| Max. Negotiated Rate |
$37.70 |
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: Humana Medicare Advantage |
$16.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.87
|
| Rate for Payer: WPPA Medicare Advantage |
$23.81
|
|
|
Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [HMC]
|
Facility
|
OP
|
$39.68
|
|
|
Service Code
|
NDC 00409792609
|
| Hospital Charge Code |
3253932
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.87 |
| Max. Negotiated Rate |
$37.70 |
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: Humana Medicare Advantage |
$16.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.87
|
| Rate for Payer: WPPA Medicare Advantage |
$23.81
|
|
|
Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [HMC]
|
Facility
|
OP
|
$36.01
|
|
|
Service Code
|
NDC 63323086910
|
| Hospital Charge Code |
3253932
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$34.21 |
| Rate for Payer: Aetna Commercial |
$32.41
|
| Rate for Payer: Humana Medicare Advantage |
$15.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.40
|
| Rate for Payer: WPPA Medicare Advantage |
$21.61
|
|
|
Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [HMC]
|
Facility
|
IP
|
$36.01
|
|
|
Service Code
|
NDC 63323086910
|
| Hospital Charge Code |
3253932
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.41 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$32.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.21
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [HMC]
|
Facility
|
IP
|
$39.68
|
|
|
Service Code
|
NDC 00990792609
|
| Hospital Charge Code |
3253932
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.71 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Dextrose 5% with NS and KCl 20 mEq/l IV Sol 1000 mL [HMC]
|
Facility
|
OP
|
$45.22
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
3800522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$42.96 |
| Rate for Payer: Aetna Commercial |
$40.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.15
|
| Rate for Payer: Humana Medicare Advantage |
$18.99
|
| Rate for Payer: UnitedHealthcare Commercial |
$42.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.12
|
| Rate for Payer: WPPA Medicare Advantage |
$27.13
|
|
|
Dextrose 5% with NS and KCl 20 mEq/l IV Sol 1000 mL [HMC]
|
Facility
|
IP
|
$45.22
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
3800522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$40.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$42.96
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Dextrose 5% with NS IV Sol 1000 mL [HMC]
|
Facility
|
IP
|
$39.68
|
|
|
Service Code
|
HCPCS J7042
|
| Hospital Charge Code |
3254013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.71 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: Aetna Commercial |
$36.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Dextrose 5% with NS IV Sol 1000 mL [HMC]
|
Facility
|
OP
|
$40.40
|
|
|
Service Code
|
HCPCS J7042
|
| Hospital Charge Code |
3254013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$38.38 |
| Rate for Payer: Aetna Commercial |
$36.36
|
| Rate for Payer: Aetna Commercial |
$35.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.45
|
| Rate for Payer: Humana Medicare Advantage |
$16.97
|
| Rate for Payer: Humana Medicare Advantage |
$16.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.31
|
| Rate for Payer: WPPA Medicare Advantage |
$24.24
|
| Rate for Payer: WPPA Medicare Advantage |
$23.81
|
|
|
DHEA Sulfate QST
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
HCPCS 82627
|
| Hospital Charge Code |
3557090
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$118.80 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$118.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$125.40
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
DHEA Sulfate QST
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
HCPCS 82627
|
| Hospital Charge Code |
3557090
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.23 |
| Max. Negotiated Rate |
$125.40 |
| Rate for Payer: Aetna Commercial |
$118.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$80.41
|
| Rate for Payer: Humana Medicare Advantage |
$55.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$125.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.23
|
| Rate for Payer: WPPA Medicare Advantage |
$79.20
|
|
|
DIABETES WITH CC
|
Facility
|
IP
|
$3,462.93
|
|
|
Service Code
|
MSDRG 638
|
| 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
|
|
