|
DIRECT TO OBS CHARGE
|
Facility
|
OP
|
$551.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3310026
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$523.45 |
| Rate for Payer: Aetna Commercial |
$495.90
|
| Rate for Payer: Humana Medicare Advantage |
$231.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$523.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.20
|
| Rate for Payer: WPPA Medicare Advantage |
$330.60
|
|
|
DIRECT TO OBS CHARGE
|
Facility
|
IP
|
$551.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3310026
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$495.90 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$495.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$523.45
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC
|
Facility
|
IP
|
$4,066.56
|
|
|
Service Code
|
MSDRG 442
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,066.56 |
| Rate for Payer: UnitedHealthcare Medicaid |
$4,066.56
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC
|
Facility
|
IP
|
$7,561.26
|
|
|
Service Code
|
MSDRG 441
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$7,561.26 |
| Rate for Payer: UnitedHealthcare Medicaid |
$7,561.26
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$2,954.61
|
|
|
Service Code
|
MSDRG 443
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$2,954.61 |
| Rate for Payer: UnitedHealthcare Medicaid |
$2,954.61
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC
|
Facility
|
IP
|
$4,320.72
|
|
|
Service Code
|
MSDRG 439
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,320.72 |
| Rate for Payer: UnitedHealthcare Medicaid |
$4,320.72
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC
|
Facility
|
IP
|
$7,656.57
|
|
|
Service Code
|
MSDRG 438
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$7,656.57 |
| Rate for Payer: UnitedHealthcare Medicaid |
$7,656.57
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$3,367.62
|
|
|
Service Code
|
MSDRG 440
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$3,367.62 |
| Rate for Payer: UnitedHealthcare Medicaid |
$3,367.62
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
DISORDERS OF PERSONALITY AND IMPULSE CONTROL
|
Facility
|
IP
|
$3,844.17
|
|
|
Service Code
|
MSDRG 883
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$3,844.17 |
| Rate for Payer: UnitedHealthcare Medicaid |
$3,844.17
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
DISORDERS OF THE BILIARY TRACT WITH CC
|
Facility
|
IP
|
$4,606.65
|
|
|
Service Code
|
MSDRG 445
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,606.65 |
| Rate for Payer: UnitedHealthcare Medicaid |
$4,606.65
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
DISORDERS OF THE BILIARY TRACT WITH MCC
|
Facility
|
IP
|
$7,052.94
|
|
|
Service Code
|
MSDRG 444
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$7,052.94 |
| Rate for Payer: UnitedHealthcare Medicaid |
$7,052.94
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC
|
Facility
|
IP
|
$3,494.70
|
|
|
Service Code
|
MSDRG 446
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$3,494.70 |
| Rate for Payer: UnitedHealthcare Medicaid |
$3,494.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
divalproex sodium 125 mg Oral EC Tab [HMC]
|
Facility
|
OP
|
$8.79
|
|
|
Service Code
|
NDC 60687085721
|
| Hospital Charge Code |
3800165
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$8.35 |
| Rate for Payer: Aetna Commercial |
$7.91
|
| Rate for Payer: Humana Medicare Advantage |
$3.69
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.52
|
| Rate for Payer: WPPA Medicare Advantage |
$5.27
|
|
|
divalproex sodium 125 mg Oral EC Tab [HMC]
|
Facility
|
OP
|
$7.67
|
|
|
Service Code
|
NDC 60687021121
|
| Hospital Charge Code |
3800165
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.07 |
| Max. Negotiated Rate |
$7.29 |
| Rate for Payer: Aetna Commercial |
$6.90
|
| Rate for Payer: Humana Medicare Advantage |
$3.22
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.07
|
| Rate for Payer: WPPA Medicare Advantage |
$4.60
|
|
|
divalproex sodium 125 mg Oral EC Tab [HMC]
|
Facility
|
IP
|
$11.39
|
|
|
Service Code
|
NDC 00074621213
|
| Hospital Charge Code |
3800165
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.82
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
divalproex sodium 125 mg Oral EC Tab [HMC]
|
Facility
|
IP
|
$7.67
|
|
|
Service Code
|
NDC 60687021121
|
| Hospital Charge Code |
3800165
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.29
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
divalproex sodium 125 mg Oral EC Tab [HMC]
|
Facility
|
IP
|
$8.79
|
|
|
Service Code
|
NDC 60687085721
|
| Hospital Charge Code |
3800165
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.91 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
divalproex sodium 125 mg Oral EC Tab [HMC]
|
Facility
|
OP
|
$11.39
|
|
|
Service Code
|
NDC 00074621213
|
| Hospital Charge Code |
3800165
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.56 |
| Max. Negotiated Rate |
$10.82 |
| Rate for Payer: Aetna Commercial |
$10.25
|
| Rate for Payer: Humana Medicare Advantage |
$4.78
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.56
|
| Rate for Payer: WPPA Medicare Advantage |
$6.83
|
|
|
divalproex sodium 250 mg Oral EC Tab [HMC]
|
Facility
|
OP
|
$8.22
|
|
|
Service Code
|
NDC 00832712301
|
| Hospital Charge Code |
3802015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$7.81 |
| Rate for Payer: Aetna Commercial |
$7.40
|
| Rate for Payer: Humana Medicare Advantage |
$3.45
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.29
|
| Rate for Payer: WPPA Medicare Advantage |
$4.93
|
|
|
divalproex sodium 250 mg Oral EC Tab [HMC]
|
Facility
|
OP
|
$10.29
|
|
|
Service Code
|
NDC 00603344221
|
| Hospital Charge Code |
3802015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.12 |
| Max. Negotiated Rate |
$9.78 |
| Rate for Payer: Aetna Commercial |
$9.26
|
| Rate for Payer: Humana Medicare Advantage |
$4.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.12
|
| Rate for Payer: WPPA Medicare Advantage |
$6.17
|
|
|
divalproex sodium 250 mg Oral EC Tab [HMC]
|
Facility
|
IP
|
$5.72
|
|
|
Service Code
|
NDC 00904686061
|
| Hospital Charge Code |
3802015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.15 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.43
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
divalproex sodium 250 mg Oral EC Tab [HMC]
|
Facility
|
IP
|
$10.29
|
|
|
Service Code
|
NDC 00603344221
|
| Hospital Charge Code |
3802015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.26 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.26
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.78
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
divalproex sodium 250 mg Oral EC Tab [HMC]
|
Facility
|
OP
|
$5.72
|
|
|
Service Code
|
NDC 00904686061
|
| Hospital Charge Code |
3802015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.29 |
| Max. Negotiated Rate |
$5.43 |
| Rate for Payer: Aetna Commercial |
$5.15
|
| Rate for Payer: Humana Medicare Advantage |
$2.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.29
|
| Rate for Payer: WPPA Medicare Advantage |
$3.43
|
|
|
divalproex sodium 250 mg Oral EC Tab [HMC]
|
Facility
|
IP
|
$8.22
|
|
|
Service Code
|
NDC 00832712301
|
| Hospital Charge Code |
3802015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.81
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
divalproex sodium 500 mg DR Tab [HMC]
|
Facility
|
OP
|
$5.70
|
|
|
Service Code
|
NDC 00904686161
|
| Hospital Charge Code |
3800267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$5.42 |
| Rate for Payer: Aetna Commercial |
$5.13
|
| Rate for Payer: Humana Medicare Advantage |
$2.39
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.28
|
| Rate for Payer: WPPA Medicare Advantage |
$3.42
|
|
