|
fentaNYL 50 mcg/hr Transderm ER Film [HMC]
|
Facility
|
OP
|
$161.13
|
|
|
Service Code
|
NDC 50458010405
|
| Hospital Charge Code |
3802754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.45 |
| Max. Negotiated Rate |
$153.07 |
| Rate for Payer: Aetna Commercial |
$145.02
|
| Rate for Payer: Humana Medicare Advantage |
$67.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$153.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.45
|
| Rate for Payer: WPPA Medicare Advantage |
$96.68
|
|
|
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
|
IP
|
$68.32
|
|
|
Service Code
|
NDC 60505708202
|
| Hospital Charge Code |
3802754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.49 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$61.49
|
| Rate for Payer: UnitedHealthcare Commercial |
$64.90
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 50 mcg/hr Transderm ER Filmk [HMC]
|
Facility
|
IP
|
$68.32
|
|
|
Service Code
|
NDC 50742055205
|
| Hospital Charge Code |
3802754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.49 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$61.49
|
| Rate for Payer: UnitedHealthcare Commercial |
$64.90
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 50 mcg/hr Transderm ER Filmk [HMC]
|
Facility
|
OP
|
$68.32
|
|
|
Service Code
|
NDC 50742055205
|
| Hospital Charge Code |
3802754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.33 |
| Max. Negotiated Rate |
$64.90 |
| Rate for Payer: Aetna Commercial |
$61.49
|
| Rate for Payer: Humana Medicare Advantage |
$28.69
|
| Rate for Payer: UnitedHealthcare Commercial |
$64.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.33
|
| Rate for Payer: WPPA Medicare Advantage |
$40.99
|
|
|
fentaNYL 50 mcg/mL 30mL Sol [HMC]
|
Facility
|
IP
|
$238.95
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3801515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$215.06 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$215.06
|
| Rate for Payer: UnitedHealthcare Commercial |
$227.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 50 mcg/mL 30mL Sol [HMC]
|
Facility
|
OP
|
$238.95
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3801515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$227.00 |
| Rate for Payer: Aetna Commercial |
$215.06
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.25
|
| Rate for Payer: Humana Medicare Advantage |
$100.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$227.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.19
|
| Rate for Payer: WPPA Medicare Advantage |
$143.37
|
|
|
fentaNYL 50 mcg/mL Sol [HMC]
|
Facility
|
IP
|
$88.17
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3802658
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.35 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$79.35
|
| Rate for Payer: UnitedHealthcare Commercial |
$83.76
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 50 mcg/mL Sol [HMC]
|
Facility
|
OP
|
$88.17
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
3802658
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$83.76 |
| Rate for Payer: Aetna Commercial |
$79.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.25
|
| Rate for Payer: Humana Medicare Advantage |
$37.03
|
| Rate for Payer: UnitedHealthcare Commercial |
$83.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.19
|
| Rate for Payer: WPPA Medicare Advantage |
$52.90
|
|
|
fentaNYL 75 mcg/hr Transderm ER Film [HMC]
|
Facility
|
OP
|
$70.32
|
|
|
Service Code
|
NDC 00378912398
|
| Hospital Charge Code |
3802374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.13 |
| Max. Negotiated Rate |
$66.80 |
| Rate for Payer: Aetna Commercial |
$63.29
|
| Rate for Payer: Humana Medicare Advantage |
$29.53
|
| Rate for Payer: UnitedHealthcare Commercial |
$66.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.13
|
| Rate for Payer: WPPA Medicare Advantage |
$42.19
|
|
|
fentaNYL 75 mcg/hr Transderm ER Film [HMC]
|
Facility
|
IP
|
$70.32
|
|
|
Service Code
|
NDC 00378912398
|
| Hospital Charge Code |
3802374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.29 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$63.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$66.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 75 mcg/hr Transderm ER Film [HMC]
|
Facility
|
IP
|
$70.32
|
|
|
Service Code
|
NDC 00406907576
|
| Hospital Charge Code |
3802374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.29 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$63.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$66.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fentaNYL 75 mcg/hr Transderm ER Film [HMC]
|
Facility
|
OP
|
$70.32
|
|
|
Service Code
|
NDC 00406907576
|
| Hospital Charge Code |
3802374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.13 |
| Max. Negotiated Rate |
$66.80 |
| Rate for Payer: Aetna Commercial |
$63.29
|
| Rate for Payer: Humana Medicare Advantage |
$29.53
|
| Rate for Payer: UnitedHealthcare Commercial |
$66.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.13
|
| Rate for Payer: WPPA Medicare Advantage |
$42.19
|
|
|
fentaNYL 75 mcg/hr Transderm ER Film [HMC]
|
Facility
|
OP
|
$98.96
|
|
|
Service Code
|
NDC 60505708302
|
| Hospital Charge Code |
3802374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.58 |
| Max. Negotiated Rate |
$94.01 |
| Rate for Payer: Aetna Commercial |
$89.06
|
| Rate for Payer: Humana Medicare Advantage |
$41.56
|
| Rate for Payer: UnitedHealthcare Commercial |
$94.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$39.58
|
| Rate for Payer: WPPA Medicare Advantage |
$59.38
|
|
|
fentaNYL 75 mcg/hr Transderm ER Film [HMC]
|
Facility
|
IP
|
$98.96
|
|
|
Service Code
|
NDC 60505708302
|
| Hospital Charge Code |
3802374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.06 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$89.06
|
| Rate for Payer: UnitedHealthcare Commercial |
$94.01
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Fentanyl Screen Urine
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS 80305 QW
|
| Hospital Charge Code |
3551305
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Fentanyl Screen Urine
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS 80305 QW
|
| Hospital Charge Code |
3551305
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$28.15 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$28.15
|
| Rate for Payer: Humana Medicare Advantage |
$10.92
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.95
|
| Rate for Payer: WPPA Medicare Advantage |
$15.60
|
|
|
Fentanyl Screen Urine DS
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
3559356
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$98.10 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$103.55
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Fentanyl Screen Urine DS
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
3559356
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.78 |
| Max. Negotiated Rate |
$150.08 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$150.08
|
| Rate for Payer: Humana Medicare Advantage |
$45.78
|
| Rate for Payer: UnitedHealthcare Commercial |
$103.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.74
|
| Rate for Payer: WPPA Medicare Advantage |
$65.40
|
|
|
ferric carboxymaltose (as elemental iron) 50 mg/mL [HMC]
|
Facility
|
IP
|
$2,690.70
|
|
|
Service Code
|
HCPCS J1439
|
| Hospital Charge Code |
3800594
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$2,556.16 |
| Rate for Payer: Aetna Commercial |
$2,421.63
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,556.16
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ferric carboxymaltose (as elemental iron) 50 mg/mL [HMC]
|
Facility
|
OP
|
$2,690.70
|
|
|
Service Code
|
HCPCS J1439
|
| Hospital Charge Code |
3800594
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$2,556.16 |
| Rate for Payer: Aetna Commercial |
$2,421.63
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.40
|
| Rate for Payer: Humana Medicare Advantage |
$1,130.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,556.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.12
|
| Rate for Payer: WPPA Medicare Advantage |
$1,614.42
|
|
|
Ferritin
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS 82728
|
| Hospital Charge Code |
3551054
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.63 |
| Max. Negotiated Rate |
$166.25 |
| Rate for Payer: Aetna Commercial |
$157.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$53.23
|
| Rate for Payer: Humana Medicare Advantage |
$73.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$166.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.63
|
| Rate for Payer: WPPA Medicare Advantage |
$105.00
|
|
|
Ferritin
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS 82728
|
| Hospital Charge Code |
3551054
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$157.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$157.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$166.25
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ferrous sulfate 324 mg Tab UD [HMC]
|
Facility
|
IP
|
$5.33
|
|
|
Service Code
|
NDC 00574060811
|
| Hospital Charge Code |
3801609
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.06
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ferrous sulfate 324 mg Tab UD [HMC]
|
Facility
|
OP
|
$5.33
|
|
|
Service Code
|
NDC 00574060811
|
| Hospital Charge Code |
3801609
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.13 |
| Max. Negotiated Rate |
$5.06 |
| Rate for Payer: Aetna Commercial |
$4.80
|
| Rate for Payer: Humana Medicare Advantage |
$2.24
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.13
|
| Rate for Payer: WPPA Medicare Advantage |
$3.20
|
|
