|
Kappa Light Chain, Total, Rand U QST
|
Facility
|
IP
|
$481.00
|
|
|
Service Code
|
HCPCS 83883
|
| Hospital Charge Code |
3553883
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$432.90 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$432.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$456.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Kappa Light Chain, Total, Rand U QST
|
Facility
|
OP
|
$481.00
|
|
|
Service Code
|
HCPCS 83883
|
| Hospital Charge Code |
3553883
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.63 |
| Max. Negotiated Rate |
$456.95 |
| Rate for Payer: Aetna Commercial |
$432.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$49.63
|
| Rate for Payer: Humana Medicare Advantage |
$202.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$456.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$192.40
|
| Rate for Payer: WPPA Medicare Advantage |
$288.60
|
|
|
Kerlix 2 Sterile Bandage Rolls
|
Facility
|
OP
|
$2.50
|
|
| Hospital Charge Code |
3251255
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: Humana Medicare Advantage |
$1.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1.50
|
|
|
Kerlix 2 Sterile Bandage Rolls
|
Facility
|
IP
|
$2.50
|
|
| Hospital Charge Code |
3251255
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.38
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Kerlix 3 Sterile Bandage Rolls
|
Facility
|
IP
|
$2.88
|
|
| Hospital Charge Code |
3251250
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.59 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.74
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Kerlix 3 Sterile Bandage Rolls
|
Facility
|
OP
|
$2.88
|
|
| Hospital Charge Code |
3251250
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: Humana Medicare Advantage |
$1.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.15
|
| Rate for Payer: WPPA Medicare Advantage |
$1.73
|
|
|
Kerlix 4 Sterile Bandage Rolls
|
Facility
|
IP
|
$2.52
|
|
| Hospital Charge Code |
3251258
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$2.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.39
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Kerlix 4 Sterile Bandage Rolls
|
Facility
|
OP
|
$2.52
|
|
| Hospital Charge Code |
3251258
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Aetna Commercial |
$2.27
|
| Rate for Payer: Humana Medicare Advantage |
$1.06
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.01
|
| Rate for Payer: WPPA Medicare Advantage |
$1.51
|
|
|
ketamine 10 mg/mL Inj Sol [HMC]
|
Facility
|
IP
|
$56.19
|
|
|
Service Code
|
NDC 67457018120
|
| Hospital Charge Code |
3170367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.57 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$50.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$53.38
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ketamine 10 mg/mL Inj Sol [HMC]
|
Facility
|
IP
|
$55.61
|
|
|
Service Code
|
NDC 42023011310
|
| Hospital Charge Code |
3170367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.05 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$52.83
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ketamine 10 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$55.61
|
|
|
Service Code
|
NDC 42023011310
|
| Hospital Charge Code |
3170367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.24 |
| Max. Negotiated Rate |
$52.83 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Humana Medicare Advantage |
$23.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$52.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.24
|
| Rate for Payer: WPPA Medicare Advantage |
$33.37
|
|
|
ketamine 10 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$56.19
|
|
|
Service Code
|
NDC 67457018120
|
| Hospital Charge Code |
3170367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.48 |
| Max. Negotiated Rate |
$53.38 |
| Rate for Payer: Aetna Commercial |
$50.57
|
| Rate for Payer: Humana Medicare Advantage |
$23.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$53.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.48
|
| Rate for Payer: WPPA Medicare Advantage |
$33.71
|
|
|
ketamine 10 mg/mL-NaCl 0.9% [HMC]
|
Facility
|
IP
|
$34.76
|
|
|
Service Code
|
NDC 61553032033
|
| Hospital Charge Code |
3170470
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.28 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$31.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.02
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ketamine 10 mg/mL-NaCl 0.9% [HMC]
|
Facility
|
OP
|
$34.76
|
|
|
Service Code
|
NDC 61553032033
|
| Hospital Charge Code |
3170470
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.90 |
| Max. Negotiated Rate |
$33.02 |
| Rate for Payer: Aetna Commercial |
$31.28
|
| Rate for Payer: Humana Medicare Advantage |
$14.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.90
|
| Rate for Payer: WPPA Medicare Advantage |
$20.86
|
|
|
ketamine 50 mg/mL Inj Sol [HMC]
|
Facility
|
IP
|
$38.16
|
|
|
Service Code
|
NDC 67457000110
|
| Hospital Charge Code |
3170382
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.34 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$34.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.25
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ketamine 50 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$36.40
|
|
|
Service Code
|
NDC 25021068310
|
| Hospital Charge Code |
3170382
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$34.58 |
| Rate for Payer: Aetna Commercial |
$32.76
|
| Rate for Payer: Humana Medicare Advantage |
$15.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.56
|
| Rate for Payer: WPPA Medicare Advantage |
$21.84
|
|
|
ketamine 50 mg/mL Inj Sol [HMC]
|
Facility
|
IP
|
$36.40
|
|
|
Service Code
|
NDC 25021068310
|
| Hospital Charge Code |
3170382
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.76 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$32.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.58
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ketamine 50 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$38.16
|
|
|
Service Code
|
NDC 67457000110
|
| Hospital Charge Code |
3170382
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.26 |
| Max. Negotiated Rate |
$36.25 |
| Rate for Payer: Aetna Commercial |
$34.34
|
| Rate for Payer: Humana Medicare Advantage |
$16.03
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.26
|
| Rate for Payer: WPPA Medicare Advantage |
$22.90
|
|
|
ketamine 50 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$36.52
|
|
|
Service Code
|
NDC 00143950810
|
| Hospital Charge Code |
3170382
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.61 |
| Max. Negotiated Rate |
$34.69 |
| Rate for Payer: Aetna Commercial |
$32.87
|
| Rate for Payer: Humana Medicare Advantage |
$15.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.61
|
| Rate for Payer: WPPA Medicare Advantage |
$21.91
|
|
|
ketamine 50 mg/mL Inj Sol [HMC]
|
Facility
|
IP
|
$36.52
|
|
|
Service Code
|
NDC 00143950810
|
| Hospital Charge Code |
3170382
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.87 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$32.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.69
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ketamine 50 mg/mL Syr Sol [HMC]
|
Facility
|
IP
|
$38.36
|
|
|
Service Code
|
NDC 70092112043
|
| Hospital Charge Code |
3170470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.52 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$34.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.44
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ketamine 50 mg/mL Syr Sol [HMC]
|
Facility
|
IP
|
$35.97
|
|
|
Service Code
|
NDC 70092912043
|
| Hospital Charge Code |
3170470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$32.37 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$32.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.17
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
ketamine 50 mg/mL Syr Sol [HMC]
|
Facility
|
OP
|
$38.36
|
|
|
Service Code
|
NDC 70092112043
|
| Hospital Charge Code |
3170470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.34 |
| Max. Negotiated Rate |
$36.44 |
| Rate for Payer: Aetna Commercial |
$34.52
|
| Rate for Payer: Humana Medicare Advantage |
$16.11
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.34
|
| Rate for Payer: WPPA Medicare Advantage |
$23.02
|
|
|
ketamine 50 mg/mL Syr Sol [HMC]
|
Facility
|
OP
|
$35.97
|
|
|
Service Code
|
NDC 70092912043
|
| Hospital Charge Code |
3170470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$34.17 |
| Rate for Payer: Aetna Commercial |
$32.37
|
| Rate for Payer: Humana Medicare Advantage |
$15.11
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.39
|
| Rate for Payer: WPPA Medicare Advantage |
$21.58
|
|
|
ketorolac 30 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$30.50
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
3803893
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$28.98 |
| Rate for Payer: Aetna Commercial |
$27.45
|
| Rate for Payer: Aetna Commercial |
$22.70
|
| Rate for Payer: Aetna Commercial |
$26.54
|
| Rate for Payer: Aetna Commercial |
$24.05
|
| Rate for Payer: Aetna Commercial |
$39.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.90
|
| Rate for Payer: Humana Medicare Advantage |
$11.22
|
| Rate for Payer: Humana Medicare Advantage |
$10.59
|
| Rate for Payer: Humana Medicare Advantage |
$12.39
|
| Rate for Payer: Humana Medicare Advantage |
$12.81
|
| Rate for Payer: Humana Medicare Advantage |
$18.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$25.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.33
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.33
|
| Rate for Payer: WPPA Medicare Advantage |
$17.69
|
| Rate for Payer: WPPA Medicare Advantage |
$16.03
|
| Rate for Payer: WPPA Medicare Advantage |
$15.13
|
| Rate for Payer: WPPA Medicare Advantage |
$18.30
|
| Rate for Payer: WPPA Medicare Advantage |
$26.11
|
|
