|
felodipine 5 mg ER Tab [HMC]
|
Facility
|
OP
|
$9.53
|
|
|
Service Code
|
NDC 13668013301
|
| Hospital Charge Code |
3806865
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.81 |
| Max. Negotiated Rate |
$9.05 |
| Rate for Payer: Aetna Commercial |
$8.58
|
| Rate for Payer: Humana Medicare Advantage |
$4.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.81
|
| Rate for Payer: WPPA Medicare Advantage |
$5.72
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$4,638.42
|
|
|
Service Code
|
MSDRG 748
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,638.42 |
| Rate for Payer: UnitedHealthcare Medicaid |
$4,638.42
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fenofibrate 145 mg Tab [HMC]
|
Facility
|
OP
|
$13.40
|
|
|
Service Code
|
NDC 60687062921
|
| Hospital Charge Code |
3803021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.36 |
| Max. Negotiated Rate |
$12.73 |
| Rate for Payer: Aetna Commercial |
$12.06
|
| Rate for Payer: Humana Medicare Advantage |
$5.63
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.36
|
| Rate for Payer: WPPA Medicare Advantage |
$8.04
|
|
|
fenofibrate 145 mg Tab [HMC]
|
Facility
|
IP
|
$19.32
|
|
|
Service Code
|
NDC 68180036109
|
| Hospital Charge Code |
3803021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.39 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$17.39
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fenofibrate 145 mg Tab [HMC]
|
Facility
|
OP
|
$19.32
|
|
|
Service Code
|
NDC 68180036109
|
| Hospital Charge Code |
3803021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.73 |
| Max. Negotiated Rate |
$18.35 |
| Rate for Payer: Aetna Commercial |
$17.39
|
| Rate for Payer: Humana Medicare Advantage |
$8.11
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.73
|
| Rate for Payer: WPPA Medicare Advantage |
$11.59
|
|
|
fenofibrate 145 mg Tab [HMC]
|
Facility
|
IP
|
$13.40
|
|
|
Service Code
|
NDC 60687062921
|
| Hospital Charge Code |
3803021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.06 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$12.06
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.73
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fenofibrate 145 mg Tab [HMC]
|
Facility
|
IP
|
$10.32
|
|
|
Service Code
|
NDC 00904716104
|
| Hospital Charge Code |
3803021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.29 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fenofibrate 145 mg Tab [HMC]
|
Facility
|
OP
|
$10.32
|
|
|
Service Code
|
NDC 00904716104
|
| Hospital Charge Code |
3803021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.13 |
| Max. Negotiated Rate |
$9.80 |
| Rate for Payer: Aetna Commercial |
$9.29
|
| Rate for Payer: Humana Medicare Advantage |
$4.33
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.13
|
| Rate for Payer: WPPA Medicare Advantage |
$6.19
|
|
|
FeNO Niox Vero Mouthpiece/Filter
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
3251720
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Humana Medicare Advantage |
$2.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.00
|
| Rate for Payer: WPPA Medicare Advantage |
$3.00
|
|
|
FeNO Niox Vero Mouthpiece/Filter
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
3251720
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.75
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 0.05 mg/mL Inj Sol 5 mL [HMC]
|
Facility
|
IP
|
$35.75
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3170182
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.17 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$32.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.96
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 0.05 mg/mL Inj Sol 5 mL [HMC]
|
Facility
|
OP
|
$35.75
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3170182
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$33.96 |
| Rate for Payer: Aetna Commercial |
$32.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.25
|
| Rate for Payer: Humana Medicare Advantage |
$15.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.19
|
| Rate for Payer: WPPA Medicare Advantage |
$21.45
|
|
|
fentaNYL 0.05 mg/mL Inj Sol [HMC]
|
Facility
|
IP
|
$28.70
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3170374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.83 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.83
|
| Rate for Payer: Aetna Commercial |
$27.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$27.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.72
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 0.05 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$28.70
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3170374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$27.27 |
| Rate for Payer: Aetna Commercial |
$25.83
|
| Rate for Payer: Aetna Commercial |
$27.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.25
|
| Rate for Payer: Humana Medicare Advantage |
$12.05
|
| Rate for Payer: Humana Medicare Advantage |
$12.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$27.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.19
|
| Rate for Payer: WPPA Medicare Advantage |
$17.22
|
| Rate for Payer: WPPA Medicare Advantage |
$18.14
|
|
|
fentaNYL 12 mcg/hr TD film, ER [HMC]
|
Facility
|
OP
|
$40.45
|
|
|
Service Code
|
NDC 00378911998
|
| Hospital Charge Code |
3800028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.18 |
| Max. Negotiated Rate |
$38.43 |
| Rate for Payer: Aetna Commercial |
$36.41
|
| Rate for Payer: Humana Medicare Advantage |
$16.99
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.18
|
| Rate for Payer: WPPA Medicare Advantage |
$24.27
|
|
|
fentaNYL 12 mcg/hr TD film, ER [HMC]
|
Facility
|
IP
|
$40.45
|
|
|
Service Code
|
NDC 00378911998
|
| Hospital Charge Code |
3800028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.41 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$36.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.43
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 25 mcg/hr Transderm ER Film [HMC]
|
Facility
|
OP
|
$38.84
|
|
|
Service Code
|
NDC 00378912198
|
| Hospital Charge Code |
3801970
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.54 |
| Max. Negotiated Rate |
$36.90 |
| Rate for Payer: Aetna Commercial |
$34.96
|
| Rate for Payer: Humana Medicare Advantage |
$16.31
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.54
|
| Rate for Payer: WPPA Medicare Advantage |
$23.30
|
|
|
fentaNYL 25 mcg/hr Transderm ER Film [HMC]
|
Facility
|
OP
|
$31.39
|
|
|
Service Code
|
NDC 00591360072
|
| Hospital Charge Code |
3801970
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$29.82 |
| Rate for Payer: Aetna Commercial |
$28.25
|
| Rate for Payer: Humana Medicare Advantage |
$13.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$29.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.56
|
| Rate for Payer: WPPA Medicare Advantage |
$18.83
|
|
|
fentaNYL 25 mcg/hr Transderm ER Film [HMC]
|
Facility
|
IP
|
$38.84
|
|
|
Service Code
|
NDC 00378912198
|
| Hospital Charge Code |
3801970
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.96 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$34.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.90
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 25 mcg/hr Transderm ER Film [HMC]
|
Facility
|
IP
|
$31.39
|
|
|
Service Code
|
NDC 00591360072
|
| Hospital Charge Code |
3801970
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.25 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$28.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$29.82
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 25 mcg/hr Transderm ER Film [HMC]
|
Facility
|
IP
|
$41.90
|
|
|
Service Code
|
NDC 60505708102
|
| Hospital Charge Code |
3801970
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.71 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$37.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$39.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 25 mcg/hr Transderm ER Film [HMC]
|
Facility
|
OP
|
$41.90
|
|
|
Service Code
|
NDC 60505708102
|
| Hospital Charge Code |
3801970
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.76 |
| Max. Negotiated Rate |
$39.80 |
| Rate for Payer: Aetna Commercial |
$37.71
|
| Rate for Payer: Humana Medicare Advantage |
$17.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$39.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.76
|
| Rate for Payer: WPPA Medicare Advantage |
$25.14
|
|
|
fentaNYL 50 mcg/hr Transderm ER Film [HMC]
|
Facility
|
IP
|
$161.13
|
|
|
Service Code
|
NDC 50458010405
|
| Hospital Charge Code |
3802754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$145.02 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$145.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$153.07
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 50 mcg/hr Transderm ER Film [HMC]
|
Facility
|
IP
|
$49.54
|
|
|
Service Code
|
NDC 00378912298
|
| Hospital Charge Code |
3802754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.59 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$44.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$47.06
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 50 mcg/hr Transderm ER Film [HMC]
|
Facility
|
OP
|
$49.54
|
|
|
Service Code
|
NDC 00378912298
|
| Hospital Charge Code |
3802754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.82 |
| Max. Negotiated Rate |
$47.06 |
| Rate for Payer: Aetna Commercial |
$44.59
|
| Rate for Payer: Humana Medicare Advantage |
$20.81
|
| Rate for Payer: UnitedHealthcare Commercial |
$47.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.82
|
| Rate for Payer: WPPA Medicare Advantage |
$29.72
|
|
