|
folic acid 5 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$120.93
|
|
|
Service Code
|
NDC 63323018410
|
| Hospital Charge Code |
3803708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.37 |
| Max. Negotiated Rate |
$114.88 |
| Rate for Payer: Aetna Commercial |
$108.84
|
| Rate for Payer: Humana Medicare Advantage |
$50.79
|
| Rate for Payer: UnitedHealthcare Commercial |
$114.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$48.37
|
| Rate for Payer: WPPA Medicare Advantage |
$72.56
|
|
|
Follicle Stimulating Hormone Level
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS 83001
|
| Hospital Charge Code |
3551450
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.58 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Aetna Commercial |
$106.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$71.29
|
| Rate for Payer: Humana Medicare Advantage |
$49.56
|
| Rate for Payer: UnitedHealthcare Commercial |
$112.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.58
|
| Rate for Payer: WPPA Medicare Advantage |
$70.80
|
|
|
Follicle Stimulating Hormone Level
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS 83001
|
| Hospital Charge Code |
3551450
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$106.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$106.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$112.10
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Food Allergy Profile QST
|
Facility
|
OP
|
$406.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
3558600
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$385.70 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$15.51
|
| Rate for Payer: Humana Medicare Advantage |
$170.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$385.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.22
|
| Rate for Payer: WPPA Medicare Advantage |
$243.60
|
|
|
Food Allergy Profile QST
|
Facility
|
IP
|
$406.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
3558600
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$365.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$385.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Food and Tree Nut Allergy Panel QST
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
3556267
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$20.90 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$15.51
|
| Rate for Payer: Humana Medicare Advantage |
$9.24
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.22
|
| Rate for Payer: WPPA Medicare Advantage |
$13.20
|
|
|
Food and Tree Nut Allergy Panel QST
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
3556267
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.80 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.90
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Food Specific IgG Allergy (Ped) Pnl QST
|
Facility
|
IP
|
$406.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
3558600
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$365.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$385.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Food Specific IgG Allergy (Ped) Pnl QST
|
Facility
|
OP
|
$406.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
3558600
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$385.70 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$15.51
|
| Rate for Payer: Humana Medicare Advantage |
$170.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$385.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.22
|
| Rate for Payer: WPPA Medicare Advantage |
$243.60
|
|
|
FOOT PROCEDURES WITH CC
|
Facility
|
IP
|
$7,370.64
|
|
|
Service Code
|
MSDRG 504
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$7,370.64 |
| Rate for Payer: UnitedHealthcare Medicaid |
$7,370.64
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
FOOT PROCEDURES WITH MCC
|
Facility
|
IP
|
$7,751.88
|
|
|
Service Code
|
MSDRG 503
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$7,751.88 |
| Rate for Payer: UnitedHealthcare Medicaid |
$7,751.88
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
FOOT PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$7,021.17
|
|
|
Service Code
|
MSDRG 505
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$7,021.17 |
| Rate for Payer: UnitedHealthcare Medicaid |
$7,021.17
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
formoterol-mometasone 5 mcg-100 mcg/inh Aer [HMC]
|
Facility
|
IP
|
$395.71
|
|
|
Service Code
|
NDC 78206012701
|
| Hospital Charge Code |
3800252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$356.14 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$356.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$375.92
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
formoterol-mometasone 5 mcg-100 mcg/inh Aer [HMC]
|
Facility
|
IP
|
$361.43
|
|
|
Service Code
|
NDC 00085720607
|
| Hospital Charge Code |
3800252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$325.29 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$325.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$343.36
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
formoterol-mometasone 5 mcg-100 mcg/inh Aer [HMC]
|
Facility
|
OP
|
$395.71
|
|
|
Service Code
|
NDC 78206012702
|
| Hospital Charge Code |
3800252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$158.28 |
| Max. Negotiated Rate |
$375.92 |
| Rate for Payer: Aetna Commercial |
$356.14
|
| Rate for Payer: Humana Medicare Advantage |
$166.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$375.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$158.28
|
| Rate for Payer: WPPA Medicare Advantage |
$237.43
|
|
|
formoterol-mometasone 5 mcg-100 mcg/inh Aer [HMC]
|
Facility
|
OP
|
$395.71
|
|
|
Service Code
|
NDC 78206012701
|
| Hospital Charge Code |
3800252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$158.28 |
| Max. Negotiated Rate |
$375.92 |
| Rate for Payer: Aetna Commercial |
$356.14
|
| Rate for Payer: Humana Medicare Advantage |
$166.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$375.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$158.28
|
| Rate for Payer: WPPA Medicare Advantage |
$237.43
|
|
|
formoterol-mometasone 5 mcg-100 mcg/inh Aer [HMC]
|
Facility
|
IP
|
$395.71
|
|
|
Service Code
|
NDC 78206012702
|
| Hospital Charge Code |
3800252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$356.14 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$356.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$375.92
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
formoterol-mometasone 5 mcg-100 mcg/inh Aer [HMC]
|
Facility
|
OP
|
$361.43
|
|
|
Service Code
|
NDC 00085720607
|
| Hospital Charge Code |
3800252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$144.57 |
| Max. Negotiated Rate |
$343.36 |
| Rate for Payer: Aetna Commercial |
$325.29
|
| Rate for Payer: Humana Medicare Advantage |
$151.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$343.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$144.57
|
| Rate for Payer: WPPA Medicare Advantage |
$216.86
|
|
|
fosaprepitant 150 mg Pow [HMC]
|
Facility
|
IP
|
$501.88
|
|
|
Service Code
|
HCPCS J1453
|
| Hospital Charge Code |
3807904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$451.69 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$451.69
|
| Rate for Payer: Aetna Commercial |
$560.11
|
| Rate for Payer: UnitedHealthcare Commercial |
$591.22
|
| Rate for Payer: UnitedHealthcare Commercial |
$476.79
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
fosaprepitant 150 mg Pow [HMC]
|
Facility
|
OP
|
$501.88
|
|
|
Service Code
|
HCPCS J1453
|
| Hospital Charge Code |
3807904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$476.79 |
| Rate for Payer: Aetna Commercial |
$451.69
|
| Rate for Payer: Aetna Commercial |
$560.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.56
|
| Rate for Payer: Humana Medicare Advantage |
$261.38
|
| Rate for Payer: Humana Medicare Advantage |
$210.79
|
| Rate for Payer: UnitedHealthcare Commercial |
$476.79
|
| Rate for Payer: UnitedHealthcare Commercial |
$591.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.11
|
| Rate for Payer: WPPA Medicare Advantage |
$301.13
|
| Rate for Payer: WPPA Medicare Advantage |
$373.40
|
|
|
FRACTURES OF FEMUR WITH MCC
|
Facility
|
IP
|
$9,594.54
|
|
|
Service Code
|
MSDRG 533
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$9,594.54 |
| Rate for Payer: UnitedHealthcare Medicaid |
$9,594.54
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
FRACTURES OF FEMUR WITHOUT MCC
|
Facility
|
IP
|
$4,956.12
|
|
|
Service Code
|
MSDRG 534
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,956.12 |
| Rate for Payer: UnitedHealthcare Medicaid |
$4,956.12
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
FRACTURES OF HIP AND PELVIS WITH MCC
|
Facility
|
IP
|
$7,847.19
|
|
|
Service Code
|
MSDRG 535
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$7,847.19 |
| Rate for Payer: UnitedHealthcare Medicaid |
$7,847.19
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
FRACTURES OF HIP AND PELVIS WITHOUT MCC
|
Facility
|
IP
|
$4,956.12
|
|
|
Service Code
|
MSDRG 536
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,956.12 |
| Rate for Payer: UnitedHealthcare Medicaid |
$4,956.12
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC
|
Facility
|
IP
|
$8,736.75
|
|
|
Service Code
|
MSDRG 562
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$8,736.75 |
| Rate for Payer: UnitedHealthcare Medicaid |
$8,736.75
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
