|
NM Thyroid Uptake Single or Multi
|
Facility
|
OP
|
$1,070.00
|
|
|
Service Code
|
HCPCS 78014 TC
|
| Hospital Charge Code |
3720060
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$218.05 |
| Max. Negotiated Rate |
$1,016.50 |
| Rate for Payer: Aetna Commercial |
$963.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$424.64
|
| Rate for Payer: Humana Medicare Advantage |
$449.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,016.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$218.05
|
| Rate for Payer: WPPA Medicare Advantage |
$642.00
|
|
|
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC
|
Facility
|
IP
|
$10,388.79
|
|
|
Service Code
|
MSDRG 098
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$10,388.79 |
| Rate for Payer: UnitedHealthcare Medicaid |
$10,388.79
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC
|
Facility
|
IP
|
$16,329.78
|
|
|
Service Code
|
MSDRG 097
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$16,329.78 |
| Rate for Payer: UnitedHealthcare Medicaid |
$16,329.78
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$6,163.38
|
|
|
Service Code
|
MSDRG 099
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$6,163.38 |
| Rate for Payer: UnitedHealthcare Medicaid |
$6,163.38
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
NON-EXTENSIVE BURNS
|
Facility
|
IP
|
$6,576.39
|
|
|
Service Code
|
MSDRG 935
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$6,576.39 |
| Rate for Payer: UnitedHealthcare Medicaid |
$6,576.39
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC
|
Facility
|
IP
|
$6,163.38
|
|
|
Service Code
|
MSDRG 988
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$6,163.38 |
| Rate for Payer: UnitedHealthcare Medicaid |
$6,163.38
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC
|
Facility
|
IP
|
$12,835.08
|
|
|
Service Code
|
MSDRG 987
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$12,835.08 |
| Rate for Payer: UnitedHealthcare Medicaid |
$12,835.08
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC
|
Facility
|
IP
|
$4,479.57
|
|
|
Service Code
|
MSDRG 989
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,479.57 |
| Rate for Payer: UnitedHealthcare Medicaid |
$4,479.57
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC
|
Facility
|
IP
|
$4,892.58
|
|
|
Service Code
|
MSDRG 600
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,892.58 |
| Rate for Payer: UnitedHealthcare Medicaid |
$4,892.58
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$2,827.53
|
|
|
Service Code
|
MSDRG 601
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$2,827.53 |
| Rate for Payer: UnitedHealthcare Medicaid |
$2,827.53
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
NONTRAUMATIC STUPOR AND COMA WITH MCC
|
Facility
|
IP
|
$4,161.87
|
|
|
Service Code
|
MSDRG 080
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,161.87 |
| Rate for Payer: UnitedHealthcare Medicaid |
$4,161.87
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC
|
Facility
|
IP
|
$3,939.48
|
|
|
Service Code
|
MSDRG 081
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$3,939.48 |
| Rate for Payer: UnitedHealthcare Medicaid |
$3,939.48
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
norepinephrine 1 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
NDC 43066099710
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Humana Medicare Advantage |
$15.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.20
|
| Rate for Payer: WPPA Medicare Advantage |
$22.80
|
|
|
norepinephrine 1 mg/mL IV Sol [HMC]
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
NDC 43066099710
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.10
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
norEPINEPHrine 1 mg/mL IV Sol [HMC]
|
Facility
|
IP
|
$51.43
|
|
|
Service Code
|
NDC 72078000204
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.29 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$46.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$48.86
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
norEPINEPHrine 1 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$40.98
|
|
|
Service Code
|
NDC 47335061544
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.39 |
| Max. Negotiated Rate |
$38.93 |
| Rate for Payer: Aetna Commercial |
$36.88
|
| Rate for Payer: Humana Medicare Advantage |
$17.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.39
|
| Rate for Payer: WPPA Medicare Advantage |
$24.59
|
|
|
norEPINEPHrine 1 mg/mL IV Sol [HMC]
|
Facility
|
IP
|
$52.44
|
|
|
Service Code
|
NDC 70121157607
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$47.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$49.82
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
norEPINEPHrine 1 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$51.43
|
|
|
Service Code
|
NDC 72078000204
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.57 |
| Max. Negotiated Rate |
$48.86 |
| Rate for Payer: Aetna Commercial |
$46.29
|
| Rate for Payer: Humana Medicare Advantage |
$21.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$48.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.57
|
| Rate for Payer: WPPA Medicare Advantage |
$30.86
|
|
|
norEPINEPHrine 1 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$52.44
|
|
|
Service Code
|
NDC 70121157607
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.98 |
| Max. Negotiated Rate |
$49.82 |
| Rate for Payer: Aetna Commercial |
$47.20
|
| Rate for Payer: Humana Medicare Advantage |
$22.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$49.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.98
|
| Rate for Payer: WPPA Medicare Advantage |
$31.46
|
|
|
norEPINEPHrine 1 mg/mL IV Sol [HMC]
|
Facility
|
IP
|
$54.60
|
|
|
Service Code
|
NDC 00143931810
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.14 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$49.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$51.87
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
norEPINEPHrine 1 mg/mL IV Sol [HMC]
|
Facility
|
IP
|
$40.98
|
|
|
Service Code
|
NDC 47335061544
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.88 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$36.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.93
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
norEPINEPHrine 1 mg/mL IV Sol [HMC]
|
Facility
|
IP
|
$52.74
|
|
|
Service Code
|
NDC 67457085204
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.47 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$47.47
|
| Rate for Payer: UnitedHealthcare Commercial |
$50.10
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
norEPINEPHrine 1 mg/mL IV Sol [HMC]
|
Facility
|
IP
|
$60.46
|
|
|
Service Code
|
NDC 00409337504
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.41 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$54.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$57.44
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
norEPINEPHrine 1 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$60.46
|
|
|
Service Code
|
NDC 00409337504
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$57.44 |
| Rate for Payer: Aetna Commercial |
$54.41
|
| Rate for Payer: Humana Medicare Advantage |
$25.39
|
| Rate for Payer: UnitedHealthcare Commercial |
$57.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.18
|
| Rate for Payer: WPPA Medicare Advantage |
$36.28
|
|
|
norEPINEPHrine 1 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$52.74
|
|
|
Service Code
|
NDC 67457085204
|
| Hospital Charge Code |
3802250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.10 |
| Max. Negotiated Rate |
$50.10 |
| Rate for Payer: Aetna Commercial |
$47.47
|
| Rate for Payer: Humana Medicare Advantage |
$22.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$50.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$21.10
|
| Rate for Payer: WPPA Medicare Advantage |
$31.64
|
|
