|
DIABETES WITH MCC
|
Facility
|
IP
|
$5,559.75
|
|
|
Service Code
|
MSDRG 637
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$5,559.75 |
| Rate for Payer: UnitedHealthcare Medicaid |
$5,559.75
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
DIABETES WITHOUT CC/MCC
|
Facility
|
IP
|
$2,255.67
|
|
|
Service Code
|
MSDRG 639
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$2,255.67 |
| Rate for Payer: UnitedHealthcare Medicaid |
$2,255.67
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
diatrizoate 66%-10% Sol [HMC]
|
Facility
|
OP
|
$63.51
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
3749963
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$60.33 |
| Rate for Payer: Aetna Commercial |
$57.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.91
|
| Rate for Payer: Humana Medicare Advantage |
$26.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$60.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.40
|
| Rate for Payer: WPPA Medicare Advantage |
$38.11
|
|
|
diatrizoate 66%-10% Sol [HMC]
|
Facility
|
IP
|
$63.51
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
3749963
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.16 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$57.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$60.33
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
diazepam 5 mg/mL Inj Sol 10 mL [HMC]
|
Facility
|
IP
|
$105.90
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
3800613
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$95.31 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$95.31
|
| Rate for Payer: UnitedHealthcare Commercial |
$100.61
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
diazepam 5 mg/mL Inj Sol 10 mL [HMC]
|
Facility
|
OP
|
$105.90
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
3800613
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$100.61 |
| Rate for Payer: Aetna Commercial |
$95.31
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$8.41
|
| Rate for Payer: Humana Medicare Advantage |
$44.48
|
| Rate for Payer: UnitedHealthcare Commercial |
$100.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.36
|
| Rate for Payer: WPPA Medicare Advantage |
$63.54
|
|
|
diazePAM 5 mg/mL Sol 2 ml [HMC]
|
Facility
|
IP
|
$64.30
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
3804982
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.87 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$57.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$61.09
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
diazePAM 5 mg/mL Sol 2 ml [HMC]
|
Facility
|
OP
|
$64.30
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
3804982
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$61.09 |
| Rate for Payer: Aetna Commercial |
$57.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$8.41
|
| Rate for Payer: Humana Medicare Advantage |
$27.01
|
| Rate for Payer: UnitedHealthcare Commercial |
$61.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.72
|
| Rate for Payer: WPPA Medicare Advantage |
$38.58
|
|
|
diazePAM 5 mg/mL Sol 2 mL [HMC]
|
Facility
|
IP
|
$64.31
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
3804982
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.88 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$57.88
|
| Rate for Payer: Aetna Commercial |
$72.53
|
| Rate for Payer: UnitedHealthcare Commercial |
$76.56
|
| Rate for Payer: UnitedHealthcare Commercial |
$61.09
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
diazePAM 5 mg/mL Sol 2 mL [HMC]
|
Facility
|
OP
|
$80.59
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
3804982
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$76.56 |
| Rate for Payer: Aetna Commercial |
$72.53
|
| Rate for Payer: Aetna Commercial |
$57.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$8.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$8.41
|
| Rate for Payer: Humana Medicare Advantage |
$27.01
|
| Rate for Payer: Humana Medicare Advantage |
$33.85
|
| Rate for Payer: UnitedHealthcare Commercial |
$61.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$76.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.72
|
| Rate for Payer: WPPA Medicare Advantage |
$38.59
|
| Rate for Payer: WPPA Medicare Advantage |
$48.35
|
|
|
diazepam 5 mg Tab [HMC]
|
Facility
|
OP
|
$5.60
|
|
|
Service Code
|
NDC 00172392660
|
| Hospital Charge Code |
3804974
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Aetna Commercial |
$5.04
|
| Rate for Payer: Humana Medicare Advantage |
$2.35
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.24
|
| Rate for Payer: WPPA Medicare Advantage |
$3.36
|
|
|
diazepam 5 mg Tab [HMC]
|
Facility
|
IP
|
$5.60
|
|
|
Service Code
|
NDC 00172392660
|
| Hospital Charge Code |
3804974
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.04 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.04
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.32
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
diazepam 5 mg Tab [HMC]
|
Facility
|
OP
|
$5.96
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
3804974
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$5.66 |
| Rate for Payer: Aetna Commercial |
$5.36
|
| Rate for Payer: Humana Medicare Advantage |
$2.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.38
|
| Rate for Payer: WPPA Medicare Advantage |
$3.58
|
|
|
diazepam 5 mg Tab [HMC]
|
Facility
|
IP
|
$5.96
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
3804974
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.36 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.66
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
dibucaine Top 1% Oint [HMC]
|
Facility
|
IP
|
$30.31
|
|
|
Service Code
|
NDC 00536121195
|
| Hospital Charge Code |
3808546
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.28 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$27.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.79
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
dibucaine Top 1% Oint [HMC]
|
Facility
|
OP
|
$30.50
|
|
|
Service Code
|
NDC 45802005003
|
| Hospital Charge Code |
3808546
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.20 |
| Max. Negotiated Rate |
$28.98 |
| Rate for Payer: Aetna Commercial |
$27.45
|
| Rate for Payer: Humana Medicare Advantage |
$12.81
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.20
|
| Rate for Payer: WPPA Medicare Advantage |
$18.30
|
|
|
dibucaine Top 1% Oint [HMC]
|
Facility
|
IP
|
$30.50
|
|
|
Service Code
|
NDC 45802005003
|
| Hospital Charge Code |
3808546
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.45 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$27.45
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.98
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
dibucaine Top 1% Oint [HMC]
|
Facility
|
OP
|
$30.31
|
|
|
Service Code
|
NDC 00536121195
|
| Hospital Charge Code |
3808546
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.12 |
| Max. Negotiated Rate |
$28.79 |
| Rate for Payer: Aetna Commercial |
$27.28
|
| Rate for Payer: Humana Medicare Advantage |
$12.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.12
|
| Rate for Payer: WPPA Medicare Advantage |
$18.19
|
|
|
diclofenac sodium 50 mg Oral EC Tab [HMC]
|
Facility
|
OP
|
$8.03
|
|
|
Service Code
|
NDC 61442010201
|
| Hospital Charge Code |
3808942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$7.63 |
| Rate for Payer: Aetna Commercial |
$7.23
|
| Rate for Payer: Humana Medicare Advantage |
$3.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.21
|
| Rate for Payer: WPPA Medicare Advantage |
$4.82
|
|
|
diclofenac sodium 50 mg Oral EC Tab [HMC]
|
Facility
|
OP
|
$9.42
|
|
|
Service Code
|
NDC 68001028000
|
| Hospital Charge Code |
3808942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.77 |
| Max. Negotiated Rate |
$8.95 |
| Rate for Payer: Aetna Commercial |
$8.48
|
| Rate for Payer: Humana Medicare Advantage |
$3.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.77
|
| Rate for Payer: WPPA Medicare Advantage |
$5.65
|
|
|
diclofenac sodium 50 mg Oral EC Tab [HMC]
|
Facility
|
IP
|
$6.90
|
|
|
Service Code
|
NDC 60687060601
|
| Hospital Charge Code |
3808942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.21 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.55
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
diclofenac sodium 50 mg Oral EC Tab [HMC]
|
Facility
|
OP
|
$6.90
|
|
|
Service Code
|
NDC 60687060601
|
| Hospital Charge Code |
3808942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.76 |
| Max. Negotiated Rate |
$6.55 |
| Rate for Payer: Aetna Commercial |
$6.21
|
| Rate for Payer: Humana Medicare Advantage |
$2.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.76
|
| Rate for Payer: WPPA Medicare Advantage |
$4.14
|
|
|
diclofenac sodium 50 mg Oral EC Tab [HMC]
|
Facility
|
IP
|
$9.42
|
|
|
Service Code
|
NDC 68001028000
|
| Hospital Charge Code |
3808942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.48 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.48
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
diclofenac sodium 50 mg Oral EC Tab [HMC]
|
Facility
|
IP
|
$8.03
|
|
|
Service Code
|
NDC 61442010201
|
| Hospital Charge Code |
3808942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.23
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.63
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
diclofenac sodium 75 mg Oral EC Tab [HMC]
|
Facility
|
OP
|
$8.43
|
|
|
Service Code
|
NDC 00591033960
|
| Hospital Charge Code |
3800745
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.37 |
| Max. Negotiated Rate |
$8.01 |
| Rate for Payer: Aetna Commercial |
$7.59
|
| Rate for Payer: Humana Medicare Advantage |
$3.54
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.37
|
| Rate for Payer: WPPA Medicare Advantage |
$5.06
|
|
