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All Charges

Charge

Type

Setting

Price

Laceration Repair- Face,Ears,Eyelid, Nose, Lip, 5.1cm-7.5cm

Facility

IP

$590.00

Service Code	HCPCS 12014
Hospital Charge Code	3300243
Hospital Revenue Code	450
Min. Negotiated Rate	$531.00
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$531.00
Rate for Payer: UnitedHealthcare Commercial	$560.50
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Laceration Repair- Face,Ears,Eyelid, Nose, Lip, 5.1cm-7.5cm

Facility

OP

$590.00

Service Code	HCPCS 12014
Hospital Charge Code	3300243
Hospital Revenue Code	450
Min. Negotiated Rate	$247.80
Max. Negotiated Rate	$560.50
Rate for Payer: Aetna Commercial	$531.00
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$475.71
Rate for Payer: Humana Medicare Advantage	$247.80
Rate for Payer: UnitedHealthcare Commercial	$560.50
Rate for Payer: UnitedHealthcare Medicaid	$336.96
Rate for Payer: WPPA Medicare Advantage	$354.00

Laceration Repair- Face,Ears,Eyelid, Nose, Lip, 7.6cm-12.5cm

Facility

OP

$1,523.00

Service Code	HCPCS 12015
Hospital Charge Code	3300244
Hospital Revenue Code	450
Min. Negotiated Rate	$336.96
Max. Negotiated Rate	$1,446.85
Rate for Payer: Aetna Commercial	$1,370.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$809.01
Rate for Payer: Humana Medicare Advantage	$639.66
Rate for Payer: UnitedHealthcare Commercial	$1,446.85
Rate for Payer: UnitedHealthcare Medicaid	$336.96
Rate for Payer: WPPA Medicare Advantage	$913.80

Laceration Repair- Face,Ears,Eyelid, Nose, Lip, 7.6cm-12.5cm

Facility

IP

$1,523.00

Service Code	HCPCS 12015
Hospital Charge Code	3300244
Hospital Revenue Code	450
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,446.85
Rate for Payer: Aetna Commercial	$1,370.70
Rate for Payer: UnitedHealthcare Commercial	$1,446.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Laceration Repair Transcribed

Facility

IP

$432.00

Service Code	HCPCS 59300
Hospital Charge Code	3209300
Hospital Revenue Code	729
Min. Negotiated Rate	$388.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$388.80
Rate for Payer: UnitedHealthcare Commercial	$410.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Laceration Repair Transcribed

Facility

OP

$432.00

Service Code	HCPCS 59300
Hospital Charge Code	3209300
Hospital Revenue Code	729
Min. Negotiated Rate	$181.44
Max. Negotiated Rate	$1,012.78
Rate for Payer: Aetna Commercial	$388.80
Rate for Payer: Humana Medicare Advantage	$181.44
Rate for Payer: UnitedHealthcare Commercial	$410.40
Rate for Payer: UnitedHealthcare Medicaid	$1,012.78
Rate for Payer: WPPA Medicare Advantage	$259.20

lacosamide 100 mg Tab UD [HMC]

Facility

OP

$29.31

Service Code	NDC 00131247860
Hospital Charge Code	3809075
Hospital Revenue Code	250
Min. Negotiated Rate	$11.72
Max. Negotiated Rate	$27.84
Rate for Payer: Aetna Commercial	$26.38
Rate for Payer: Humana Medicare Advantage	$12.31
Rate for Payer: UnitedHealthcare Commercial	$27.84
Rate for Payer: UnitedHealthcare Medicaid	$11.72
Rate for Payer: WPPA Medicare Advantage	$17.59

lacosamide 100 mg Tab UD [HMC]

Facility

OP

$27.10

Service Code	NDC 00131247835
Hospital Charge Code	3809075
Hospital Revenue Code	250
Min. Negotiated Rate	$10.84
Max. Negotiated Rate	$25.75
Rate for Payer: Aetna Commercial	$24.39
Rate for Payer: Humana Medicare Advantage	$11.38
Rate for Payer: UnitedHealthcare Commercial	$25.75
Rate for Payer: UnitedHealthcare Medicaid	$10.84
Rate for Payer: WPPA Medicare Advantage	$16.26

lacosamide 100 mg Tab UD [HMC]

Facility

IP

$27.10

Service Code	NDC 00131247835
Hospital Charge Code	3809075
Hospital Revenue Code	250
Min. Negotiated Rate	$24.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.39
Rate for Payer: UnitedHealthcare Commercial	$25.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lacosamide 100 mg Tab UD [HMC]

Facility

OP

$38.62

Service Code	NDC 62332017260
Hospital Charge Code	3809075
Hospital Revenue Code	250
Min. Negotiated Rate	$15.45
Max. Negotiated Rate	$36.69
Rate for Payer: Aetna Commercial	$34.76
Rate for Payer: Humana Medicare Advantage	$16.22
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicaid	$15.45
Rate for Payer: WPPA Medicare Advantage	$23.17

lacosamide 100 mg Tab UD [HMC]

Facility

IP

$29.31

Service Code	NDC 00131247860
Hospital Charge Code	3809075
Hospital Revenue Code	250
Min. Negotiated Rate	$26.38
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.38
Rate for Payer: UnitedHealthcare Commercial	$27.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

lacosamide 100 mg Tab UD [HMC]

Facility

IP

$38.62

Service Code	NDC 62332017260
Hospital Charge Code	3809075
Hospital Revenue Code	250
Min. Negotiated Rate	$34.76
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.76
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lacosamide QST

Facility

OP

$262.55

Service Code	HCPCS 80235
Hospital Charge Code	3550235
Hospital Revenue Code	300
Min. Negotiated Rate	$23.04
Max. Negotiated Rate	$249.42
Rate for Payer: Aetna Commercial	$236.29
Rate for Payer: Humana Medicare Advantage	$110.27
Rate for Payer: UnitedHealthcare Commercial	$249.42
Rate for Payer: UnitedHealthcare Medicaid	$23.04
Rate for Payer: WPPA Medicare Advantage	$157.53

Lacosamide QST

Facility

IP

$262.55

Service Code	HCPCS 80235
Hospital Charge Code	3550235
Hospital Revenue Code	300
Min. Negotiated Rate	$236.29
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$236.29
Rate for Payer: UnitedHealthcare Commercial	$249.42
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lactate Dehydrogenase

Facility

IP

$83.00

Service Code	HCPCS 83625
Hospital Charge Code	3553625
Hospital Revenue Code	300
Min. Negotiated Rate	$74.70
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$74.70
Rate for Payer: UnitedHealthcare Commercial	$78.85
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lactate Dehydrogenase

Facility

OP

$83.00

Service Code	HCPCS 83625
Hospital Charge Code	3553625
Hospital Revenue Code	300
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$78.85
Rate for Payer: Aetna Commercial	$74.70
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.08
Rate for Payer: Humana Medicare Advantage	$34.86
Rate for Payer: UnitedHealthcare Commercial	$78.85
Rate for Payer: UnitedHealthcare Medicaid	$12.79
Rate for Payer: WPPA Medicare Advantage	$49.80

Lactate Dehydrogenase Isoenzyme Pnl QST

Facility

IP

$72.00

Service Code	HCPCS 83625
Hospital Charge Code	3553625
Hospital Revenue Code	300
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lactate Dehydrogenase Isoenzyme Pnl QST

Facility

IP

$72.00

Service Code	HCPCS 83615
Hospital Charge Code	3553625
Hospital Revenue Code	300
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lactate Dehydrogenase Isoenzyme Pnl QST

Facility

OP

$72.00

Service Code	HCPCS 83625
Hospital Charge Code	3553625
Hospital Revenue Code	300
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$47.08
Rate for Payer: Humana Medicare Advantage	$30.24
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: UnitedHealthcare Medicaid	$12.79
Rate for Payer: WPPA Medicare Advantage	$43.20

Lactate Dehydrogenase Isoenzyme Pnl QST

Facility

OP

$72.00

Service Code	HCPCS 83615
Hospital Charge Code	3553625
Hospital Revenue Code	300
Min. Negotiated Rate	$6.04
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna Commercial	$64.80
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$22.78
Rate for Payer: Humana Medicare Advantage	$30.24
Rate for Payer: UnitedHealthcare Commercial	$68.40
Rate for Payer: UnitedHealthcare Medicaid	$6.04
Rate for Payer: WPPA Medicare Advantage	$43.20

Lactated Ringers IV Sol 1000 mL [HMC]

Facility

OP

$40.40

Service Code	HCPCS J7120
Hospital Charge Code	3254054
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$38.38
Rate for Payer: Aetna Commercial	$36.36
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.12
Rate for Payer: Humana Medicare Advantage	$16.97
Rate for Payer: UnitedHealthcare Commercial	$38.38
Rate for Payer: UnitedHealthcare Medicaid	$2.38
Rate for Payer: WPPA Medicare Advantage	$24.24

Lactated Ringers IV Sol 1000 mL [HMC]

Facility

IP

$40.40

Service Code	HCPCS J7120
Hospital Charge Code	3254054
Hospital Revenue Code	250
Min. Negotiated Rate	$36.36
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.36
Rate for Payer: UnitedHealthcare Commercial	$38.38
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lactated Ringers IV Sol 250 mL [HMC]

Facility

IP

$39.68

Service Code	HCPCS J7120
Hospital Charge Code	3257520
Hospital Revenue Code	250
Min. Negotiated Rate	$35.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.71
Rate for Payer: UnitedHealthcare Commercial	$37.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Lactated Ringers IV Sol 250 mL [HMC]

Facility

OP

$39.68

Service Code	HCPCS J7120
Hospital Charge Code	3257520
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$37.70
Rate for Payer: Aetna Commercial	$35.71
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.12
Rate for Payer: Humana Medicare Advantage	$16.67
Rate for Payer: UnitedHealthcare Commercial	$37.70
Rate for Payer: UnitedHealthcare Medicaid	$2.38
Rate for Payer: WPPA Medicare Advantage	$23.81

Lactated Ringers IV Sol 500 mL [HMC]

Facility

OP

$39.68

Service Code	HCPCS J7120
Hospital Charge Code	3256943
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$37.70
Rate for Payer: Aetna Commercial	$35.71
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$3.12
Rate for Payer: Humana Medicare Advantage	$16.67
Rate for Payer: UnitedHealthcare Commercial	$37.70
Rate for Payer: UnitedHealthcare Medicaid	$2.38
Rate for Payer: WPPA Medicare Advantage	$23.81

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