|
losartan 50 mg Tab [HMC]
|
Facility
|
OP
|
$11.79
|
|
|
Service Code
|
NDC 65862020290
|
| Hospital Charge Code |
3800980
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.72 |
| Max. Negotiated Rate |
$11.20 |
| Rate for Payer: Aetna Commercial |
$10.61
|
| Rate for Payer: Humana Medicare Advantage |
$4.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.72
|
| Rate for Payer: WPPA Medicare Advantage |
$7.07
|
|
|
losartan 50 mg Tab [HMC]
|
Facility
|
OP
|
$7.43
|
|
|
Service Code
|
NDC 00904704861
|
| Hospital Charge Code |
3800980
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$7.06 |
| Rate for Payer: Aetna Commercial |
$6.69
|
| Rate for Payer: Humana Medicare Advantage |
$3.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.97
|
| Rate for Payer: WPPA Medicare Advantage |
$4.46
|
|
|
losartan 50 mg Tab [HMC]
|
Facility
|
IP
|
$11.79
|
|
|
Service Code
|
NDC 65862020299
|
| Hospital Charge Code |
3800980
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.61 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.61
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
losartan 50 mg Tab [HMC]
|
Facility
|
OP
|
$11.75
|
|
|
Service Code
|
NDC 68084034701
|
| Hospital Charge Code |
3800980
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$11.16 |
| Rate for Payer: Aetna Commercial |
$10.57
|
| Rate for Payer: Humana Medicare Advantage |
$4.93
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.70
|
| Rate for Payer: WPPA Medicare Advantage |
$7.05
|
|
|
losartan 50 mg Tab [HMC]
|
Facility
|
IP
|
$11.75
|
|
|
Service Code
|
NDC 68084034701
|
| Hospital Charge Code |
3800980
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.57 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.16
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
losartan 50 mg Tab [HMC]
|
Facility
|
IP
|
$11.79
|
|
|
Service Code
|
NDC 65862020290
|
| Hospital Charge Code |
3800980
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.61 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.61
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lovastatin 20 mg Tab [HMC]
|
Facility
|
IP
|
$12.12
|
|
|
Service Code
|
NDC 68180046801
|
| Hospital Charge Code |
3805741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.91 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.51
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lovastatin 20 mg Tab [HMC]
|
Facility
|
OP
|
$12.12
|
|
|
Service Code
|
NDC 68180046807
|
| Hospital Charge Code |
3805741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.85 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: Humana Medicare Advantage |
$5.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.85
|
| Rate for Payer: WPPA Medicare Advantage |
$7.27
|
|
|
lovastatin 20 mg Tab [HMC]
|
Facility
|
OP
|
$12.12
|
|
|
Service Code
|
NDC 68180046801
|
| Hospital Charge Code |
3805741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.85 |
| Max. Negotiated Rate |
$11.51 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: Humana Medicare Advantage |
$5.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.85
|
| Rate for Payer: WPPA Medicare Advantage |
$7.27
|
|
|
lovastatin 20 mg Tab [HMC]
|
Facility
|
IP
|
$12.12
|
|
|
Service Code
|
NDC 68180046807
|
| Hospital Charge Code |
3805741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.91 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$10.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.51
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC
|
Facility
|
IP
|
$9,372.15
|
|
|
Service Code
|
MSDRG 493
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$9,372.15 |
| Rate for Payer: UnitedHealthcare Medicaid |
$9,372.15
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC
|
Facility
|
IP
|
$15,154.29
|
|
|
Service Code
|
MSDRG 492
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$15,154.29 |
| Rate for Payer: UnitedHealthcare Medicaid |
$15,154.29
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC
|
Facility
|
IP
|
$5,623.29
|
|
|
Service Code
|
MSDRG 494
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$5,623.29 |
| Rate for Payer: UnitedHealthcare Medicaid |
$5,623.29
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lubiprostone 24 mcg oral capsule [HMC]
|
Facility
|
OP
|
$21.70
|
|
|
Service Code
|
NDC 00254302902
|
| Hospital Charge Code |
3800181
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$20.61 |
| Rate for Payer: Aetna Commercial |
$19.53
|
| Rate for Payer: Humana Medicare Advantage |
$9.11
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.68
|
| Rate for Payer: WPPA Medicare Advantage |
$13.02
|
|
|
lubiprostone 24 mcg oral capsule [HMC]
|
Facility
|
OP
|
$22.63
|
|
|
Service Code
|
NDC 00480413806
|
| Hospital Charge Code |
3800181
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$21.50 |
| Rate for Payer: Aetna Commercial |
$20.37
|
| Rate for Payer: Humana Medicare Advantage |
$9.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$21.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.05
|
| Rate for Payer: WPPA Medicare Advantage |
$13.58
|
|
|
lubiprostone 24 mcg oral capsule [HMC]
|
Facility
|
IP
|
$23.56
|
|
|
Service Code
|
NDC 64764024060
|
| Hospital Charge Code |
3800181
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$21.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$22.38
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lubiprostone 24 mcg oral capsule [HMC]
|
Facility
|
OP
|
$23.56
|
|
|
Service Code
|
NDC 64764024060
|
| Hospital Charge Code |
3800181
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.42 |
| Max. Negotiated Rate |
$22.38 |
| Rate for Payer: Aetna Commercial |
$21.20
|
| Rate for Payer: Humana Medicare Advantage |
$9.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$22.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.42
|
| Rate for Payer: WPPA Medicare Advantage |
$14.14
|
|
|
lubiprostone 24 mcg oral capsule [HMC]
|
Facility
|
IP
|
$21.70
|
|
|
Service Code
|
NDC 00254302902
|
| Hospital Charge Code |
3800181
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.53 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$19.53
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.61
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lubiprostone 24 mcg oral capsule [HMC]
|
Facility
|
IP
|
$22.63
|
|
|
Service Code
|
NDC 00480413806
|
| Hospital Charge Code |
3800181
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.37 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$20.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$21.50
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Lumason sulfur hexafluoride [HMC]
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
HCPCS Q9950
|
| Hospital Charge Code |
3802255
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$252.90 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$252.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$266.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Lumason sulfur hexafluoride [HMC]
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
HCPCS Q9950
|
| Hospital Charge Code |
3802255
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.34 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Aetna Commercial |
$252.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$27.34
|
| Rate for Payer: Humana Medicare Advantage |
$118.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$266.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$112.40
|
| Rate for Payer: WPPA Medicare Advantage |
$168.60
|
|
|
Lumbar Facet Medial Branch Block #2
|
Facility
|
OP
|
$1,616.00
|
|
|
Service Code
|
HCPCS 64494
|
| Hospital Charge Code |
3154494
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$92.58 |
| Max. Negotiated Rate |
$1,535.20 |
| Rate for Payer: Aetna Commercial |
$1,454.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$984.68
|
| Rate for Payer: Humana Medicare Advantage |
$678.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,535.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$92.58
|
| Rate for Payer: WPPA Medicare Advantage |
$969.60
|
|
|
Lumbar Facet Medial Branch Block #2
|
Facility
|
IP
|
$1,616.00
|
|
|
Service Code
|
HCPCS 64494
|
| Hospital Charge Code |
3154494
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$1,535.20 |
| Rate for Payer: Aetna Commercial |
$1,454.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,535.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Lumbar Facet Medial Branch Block #3
|
Facility
|
IP
|
$2,276.00
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
3154495
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$2,162.20 |
| Rate for Payer: Aetna Commercial |
$2,048.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,162.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Lumbar Facet Medial Branch Block #3
|
Facility
|
OP
|
$2,276.00
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
3154495
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$92.58 |
| Max. Negotiated Rate |
$2,162.20 |
| Rate for Payer: Aetna Commercial |
$2,048.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1,403.26
|
| Rate for Payer: Humana Medicare Advantage |
$955.92
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,162.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$92.58
|
| Rate for Payer: WPPA Medicare Advantage |
$1,365.60
|
|
