|
OT Wheelchair Management Assistant Units
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS 97542 GO
|
| Hospital Charge Code |
3970210
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$104.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$104.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$110.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
OT Wheelchair Management Assistant Units
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS 97542 GO
|
| Hospital Charge Code |
3970210
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$29.54 |
| Max. Negotiated Rate |
$110.20 |
| Rate for Payer: Aetna Commercial |
$104.40
|
| Rate for Payer: Humana Medicare Advantage |
$48.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$110.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.54
|
| Rate for Payer: WPPA Medicare Advantage |
$69.60
|
|
|
OT Whirlpool, Fluidotherapy Units
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS 97022 GO
|
| Hospital Charge Code |
3977022
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$66.60 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$66.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$70.30
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
OT Whirlpool, Fluidotherapy Units
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS 97022 GO
|
| Hospital Charge Code |
3977022
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$14.41 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Aetna Commercial |
$66.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$33.33
|
| Rate for Payer: Humana Medicare Advantage |
$31.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$70.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.41
|
| Rate for Payer: WPPA Medicare Advantage |
$44.40
|
|
|
OT Whirlpool Therapy Assistant Units
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS 97022 GO
|
| Hospital Charge Code |
3977022
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$14.41 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Aetna Commercial |
$66.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$33.33
|
| Rate for Payer: Humana Medicare Advantage |
$31.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$70.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.41
|
| Rate for Payer: WPPA Medicare Advantage |
$44.40
|
|
|
OT Whirlpool Therapy Assistant Units
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS 97022 GO
|
| Hospital Charge Code |
3977022
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$66.60 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$66.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$70.30
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Ova +Parasites, Conc And Perm Smear QST
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
HCPCS 87177
|
| Hospital Charge Code |
3551039
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$48.45 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$31.41
|
| Rate for Payer: Humana Medicare Advantage |
$21.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$48.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.40
|
| Rate for Payer: WPPA Medicare Advantage |
$30.60
|
|
|
Ova +Parasites, Conc And Perm Smear QST
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
HCPCS 87177
|
| Hospital Charge Code |
3551039
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.90 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$48.45
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
oxacillin 2 g Inj [HMC]
|
Facility
|
OP
|
$62.05
|
|
|
Service Code
|
HCPCS J2700
|
| Hospital Charge Code |
3800112
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$58.95 |
| Rate for Payer: Aetna Commercial |
$55.84
|
| Rate for Payer: Aetna Commercial |
$56.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.70
|
| Rate for Payer: Humana Medicare Advantage |
$26.21
|
| Rate for Payer: Humana Medicare Advantage |
$26.06
|
| Rate for Payer: UnitedHealthcare Commercial |
$59.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$58.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.57
|
| Rate for Payer: WPPA Medicare Advantage |
$37.45
|
| Rate for Payer: WPPA Medicare Advantage |
$37.23
|
|
|
oxacillin 2 g Inj [HMC]
|
Facility
|
IP
|
$62.05
|
|
|
Service Code
|
HCPCS J2700
|
| Hospital Charge Code |
3800112
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.84 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$55.84
|
| Rate for Payer: Aetna Commercial |
$56.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$59.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$58.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Oxalate 24 Hour Urine ALI
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS 83945
|
| Hospital Charge Code |
3553945
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.30 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$63.65
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Oxalate 24 Hour Urine ALI
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
HCPCS 83945
|
| Hospital Charge Code |
3553945
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.28 |
| Max. Negotiated Rate |
$63.65 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$48.36
|
| Rate for Payer: Humana Medicare Advantage |
$28.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$63.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.28
|
| Rate for Payer: WPPA Medicare Advantage |
$40.20
|
|
|
oxcarbazepine 150 mg Tab [HMC]
|
Facility
|
OP
|
$9.53
|
|
|
Service Code
|
NDC 62584014201
|
| Hospital Charge Code |
3806594
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.81 |
| Max. Negotiated Rate |
$9.05 |
| Rate for Payer: Aetna Commercial |
$8.58
|
| Rate for Payer: Humana Medicare Advantage |
$4.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.81
|
| Rate for Payer: WPPA Medicare Advantage |
$5.72
|
|
|
oxcarbazepine 150 mg Tab [HMC]
|
Facility
|
IP
|
$9.53
|
|
|
Service Code
|
NDC 62584014201
|
| Hospital Charge Code |
3806594
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.58
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.05
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
oxcarbazepine 150 mg Tab [HMC]
|
Facility
|
IP
|
$9.53
|
|
|
Service Code
|
NDC 68084084501
|
| Hospital Charge Code |
3806594
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.58
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.05
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
oxcarbazepine 150 mg Tab [HMC]
|
Facility
|
OP
|
$7.05
|
|
|
Service Code
|
NDC 00904726261
|
| Hospital Charge Code |
3806594
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.34
|
| Rate for Payer: Humana Medicare Advantage |
$2.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.82
|
| Rate for Payer: WPPA Medicare Advantage |
$4.23
|
|
|
oxcarbazepine 150 mg Tab [HMC]
|
Facility
|
IP
|
$7.05
|
|
|
Service Code
|
NDC 00904726261
|
| Hospital Charge Code |
3806594
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
oxcarbazepine 150 mg Tab [HMC]
|
Facility
|
OP
|
$9.53
|
|
|
Service Code
|
NDC 68084084501
|
| Hospital Charge Code |
3806594
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.81 |
| Max. Negotiated Rate |
$9.05 |
| Rate for Payer: Aetna Commercial |
$8.58
|
| Rate for Payer: Humana Medicare Advantage |
$4.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.81
|
| Rate for Payer: WPPA Medicare Advantage |
$5.72
|
|
|
Oxcarbazepine Metabolite QST
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
HCPCS 80183
|
| Hospital Charge Code |
3550183
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.08 |
| Max. Negotiated Rate |
$101.65 |
| Rate for Payer: Aetna Commercial |
$96.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$36.08
|
| Rate for Payer: Humana Medicare Advantage |
$44.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$101.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.80
|
| Rate for Payer: WPPA Medicare Advantage |
$64.20
|
|
|
Oxcarbazepine Metabolite QST
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS 80183
|
| Hospital Charge Code |
3550183
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$96.30 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$96.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$101.65
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
oxybutynin 5 mg Tab [HMC]
|
Facility
|
IP
|
$6.51
|
|
|
Service Code
|
NDC 68084040001
|
| Hospital Charge Code |
3806516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.18
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
oxybutynin 5 mg Tab [HMC]
|
Facility
|
IP
|
$7.16
|
|
|
Service Code
|
NDC 00904702761
|
| Hospital Charge Code |
3806516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.44 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
oxybutynin 5 mg Tab [HMC]
|
Facility
|
OP
|
$6.98
|
|
|
Service Code
|
NDC 00832003801
|
| Hospital Charge Code |
3806516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$6.63 |
| Rate for Payer: Aetna Commercial |
$6.28
|
| Rate for Payer: Humana Medicare Advantage |
$2.93
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.79
|
| Rate for Payer: WPPA Medicare Advantage |
$4.19
|
|
|
oxybutynin 5 mg Tab [HMC]
|
Facility
|
OP
|
$6.51
|
|
|
Service Code
|
NDC 68084040001
|
| Hospital Charge Code |
3806516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$6.18 |
| Rate for Payer: Aetna Commercial |
$5.86
|
| Rate for Payer: Humana Medicare Advantage |
$2.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.60
|
| Rate for Payer: WPPA Medicare Advantage |
$3.91
|
|
|
oxybutynin 5 mg Tab [HMC]
|
Facility
|
IP
|
$6.98
|
|
|
Service Code
|
NDC 00832003801
|
| Hospital Charge Code |
3806516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.63
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
