|
lysine 500 mg Tab [HMC]
|
Facility
|
IP
|
$5.08
|
|
|
Service Code
|
NDC 00536673101
|
| Hospital Charge Code |
3800541
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.57 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.83
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lysine 500 mg Tab [HMC]
|
Facility
|
OP
|
$5.14
|
|
|
Service Code
|
NDC 00904268760
|
| Hospital Charge Code |
3800541
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$4.88 |
| Rate for Payer: Aetna Commercial |
$4.63
|
| Rate for Payer: Humana Medicare Advantage |
$2.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.06
|
| Rate for Payer: WPPA Medicare Advantage |
$3.08
|
|
|
lysine 500 mg Tab [HMC]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 79854060055
|
| Hospital Charge Code |
3800541
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Humana Medicare Advantage |
$2.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.00
|
| Rate for Payer: WPPA Medicare Advantage |
$3.00
|
|
|
M0239 BAMLANIVIMAB INFUSION
|
Facility
|
OP
|
$743.00
|
|
| Hospital Charge Code |
3290239
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$297.20 |
| Max. Negotiated Rate |
$705.85 |
| Rate for Payer: Aetna Commercial |
$668.70
|
| Rate for Payer: Humana Medicare Advantage |
$312.06
|
| Rate for Payer: UnitedHealthcare Commercial |
$705.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$297.20
|
| Rate for Payer: WPPA Medicare Advantage |
$445.80
|
|
|
M0239 BAMLANIVIMAB INFUSION
|
Facility
|
IP
|
$743.00
|
|
| Hospital Charge Code |
3290239
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$668.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$668.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$705.85
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
MACKEREL (f206) IgE QST
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
3552807
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
MACKEREL (f206) IgE QST
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
3552807
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$15.51
|
| Rate for Payer: Humana Medicare Advantage |
$8.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.22
|
| Rate for Payer: WPPA Medicare Advantage |
$12.60
|
|
|
magnesium citrate 1.745 g/30 mL Liq [HMC]
|
Facility
|
IP
|
$27.19
|
|
|
Service Code
|
NDC 71399788901
|
| Hospital Charge Code |
3808447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.47 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$24.47
|
| Rate for Payer: UnitedHealthcare Commercial |
$25.83
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
magnesium citrate 1.745 g/30 mL Liq [HMC]
|
Facility
|
OP
|
$27.19
|
|
|
Service Code
|
NDC 71399788901
|
| Hospital Charge Code |
3808447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.88 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$24.47
|
| Rate for Payer: Humana Medicare Advantage |
$11.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$25.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.88
|
| Rate for Payer: WPPA Medicare Advantage |
$16.31
|
|
|
magnesium citrate 8.85% Oral Liq 300 mL [HMC]
|
Facility
|
OP
|
$22.86
|
|
|
Service Code
|
NDC 24385067510
|
| Hospital Charge Code |
3808447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.14 |
| Max. Negotiated Rate |
$21.72 |
| Rate for Payer: Aetna Commercial |
$20.57
|
| Rate for Payer: Humana Medicare Advantage |
$9.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$21.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.14
|
| Rate for Payer: WPPA Medicare Advantage |
$13.72
|
|
|
magnesium citrate 8.85% Oral Liq 300 mL [HMC]
|
Facility
|
IP
|
$22.86
|
|
|
Service Code
|
NDC 24385067510
|
| Hospital Charge Code |
3808447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.57 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$20.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$21.72
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
magnesium citrate 8.85% Oral Liq 300 mL [HMC]
|
Facility
|
OP
|
$22.84
|
|
|
Service Code
|
NDC 70000066101
|
| Hospital Charge Code |
3808447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.14 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Aetna Commercial |
$20.56
|
| Rate for Payer: Humana Medicare Advantage |
$9.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$21.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.14
|
| Rate for Payer: WPPA Medicare Advantage |
$13.70
|
|
|
magnesium citrate 8.85% Oral Liq 300 mL [HMC]
|
Facility
|
IP
|
$22.84
|
|
|
Service Code
|
NDC 70000066101
|
| Hospital Charge Code |
3808447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.56 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$20.56
|
| Rate for Payer: UnitedHealthcare Commercial |
$21.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
magnesium hydroxide 8% Oral Susp 30 mL [HMC]
|
Facility
|
IP
|
$14.68
|
|
|
Service Code
|
NDC 00121043130
|
| Hospital Charge Code |
3802599
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.21 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$13.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
magnesium hydroxide 8% Oral Susp 30 mL [HMC]
|
Facility
|
OP
|
$14.68
|
|
|
Service Code
|
NDC 00121043130
|
| Hospital Charge Code |
3802599
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.87 |
| Max. Negotiated Rate |
$13.95 |
| Rate for Payer: Aetna Commercial |
$13.21
|
| Rate for Payer: Humana Medicare Advantage |
$6.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.87
|
| Rate for Payer: WPPA Medicare Advantage |
$8.81
|
|
|
Magnesium Level
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
HCPCS 83735
|
| Hospital Charge Code |
3550544
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.10 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$84.55
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Magnesium Level
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
HCPCS 83735
|
| Hospital Charge Code |
3550544
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$25.85
|
| Rate for Payer: Humana Medicare Advantage |
$37.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$84.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.70
|
| Rate for Payer: WPPA Medicare Advantage |
$53.40
|
|
|
magnesium oxide 400 mg Tab [HMC]
|
Facility
|
OP
|
$5.26
|
|
|
Service Code
|
NDC 10006070028
|
| Hospital Charge Code |
3800816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.73
|
| Rate for Payer: Humana Medicare Advantage |
$2.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.10
|
| Rate for Payer: WPPA Medicare Advantage |
$3.16
|
|
|
magnesium oxide 400 mg Tab [HMC]
|
Facility
|
IP
|
$5.44
|
|
|
Service Code
|
NDC 64980033901
|
| Hospital Charge Code |
3800816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.17
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
magnesium oxide 400 mg Tab [HMC]
|
Facility
|
OP
|
$5.18
|
|
|
Service Code
|
NDC 10006073038
|
| Hospital Charge Code |
3800816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$4.92 |
| Rate for Payer: Aetna Commercial |
$4.66
|
| Rate for Payer: Humana Medicare Advantage |
$2.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.07
|
| Rate for Payer: WPPA Medicare Advantage |
$3.11
|
|
|
magnesium oxide 400 mg Tab [HMC]
|
Facility
|
IP
|
$5.26
|
|
|
Service Code
|
NDC 10006070028
|
| Hospital Charge Code |
3800816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.73 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
magnesium oxide 400 mg Tab [HMC]
|
Facility
|
IP
|
$5.18
|
|
|
Service Code
|
NDC 10006073038
|
| Hospital Charge Code |
3800816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.66 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.66
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.92
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
magnesium oxide 400 mg Tab [HMC]
|
Facility
|
OP
|
$5.44
|
|
|
Service Code
|
NDC 64980033901
|
| Hospital Charge Code |
3800816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$5.17 |
| Rate for Payer: Aetna Commercial |
$4.90
|
| Rate for Payer: Humana Medicare Advantage |
$2.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.18
|
| Rate for Payer: WPPA Medicare Advantage |
$3.26
|
|
|
magnesium sulfate 4 g/50 mL-sterile water [HMC]
|
Facility
|
IP
|
$48.93
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
3800701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.04 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$44.04
|
| Rate for Payer: Aetna Commercial |
$36.39
|
| Rate for Payer: Aetna Commercial |
$41.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$43.61
|
| Rate for Payer: UnitedHealthcare Commercial |
$46.48
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
magnesium sulfate 4 g/50 mL-sterile water [HMC]
|
Facility
|
OP
|
$45.91
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
3800701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$43.61 |
| Rate for Payer: Aetna Commercial |
$41.32
|
| Rate for Payer: Aetna Commercial |
$44.04
|
| Rate for Payer: Aetna Commercial |
$36.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.83
|
| Rate for Payer: Humana Medicare Advantage |
$20.55
|
| Rate for Payer: Humana Medicare Advantage |
$16.98
|
| Rate for Payer: Humana Medicare Advantage |
$19.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$46.48
|
| Rate for Payer: UnitedHealthcare Commercial |
$43.61
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.41
|
| Rate for Payer: WPPA Medicare Advantage |
$29.36
|
| Rate for Payer: WPPA Medicare Advantage |
$24.26
|
| Rate for Payer: WPPA Medicare Advantage |
$27.55
|
|
