|
polycarbophil 625 mg Tab [HMC]
|
Facility
|
OP
|
$5.33
|
|
|
Service Code
|
NDC 00536430608
|
| Hospital Charge Code |
3805377
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.13 |
| Max. Negotiated Rate |
$5.06 |
| Rate for Payer: Aetna Commercial |
$4.80
|
| Rate for Payer: Humana Medicare Advantage |
$2.24
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.13
|
| Rate for Payer: WPPA Medicare Advantage |
$3.20
|
|
|
polyethylene glycol 3350 -Oral Pow for recon [HMC]
|
Facility
|
OP
|
$23.10
|
|
|
Service Code
|
NDC 00904693181
|
| Hospital Charge Code |
3809722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$21.95 |
| Rate for Payer: Aetna Commercial |
$20.79
|
| Rate for Payer: Humana Medicare Advantage |
$9.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$21.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.24
|
| Rate for Payer: WPPA Medicare Advantage |
$13.86
|
|
|
polyethylene glycol 3350 -Oral Pow for recon [HMC]
|
Facility
|
IP
|
$23.10
|
|
|
Service Code
|
NDC 00904693181
|
| Hospital Charge Code |
3809722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.79 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$20.79
|
| Rate for Payer: UnitedHealthcare Commercial |
$21.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
polyethylene glycol 3350 Oral Pwdr for Recon 238 g [HMC]
|
Facility
|
OP
|
$13.99
|
|
|
Service Code
|
NDC 00536105224
|
| Hospital Charge Code |
3800029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$13.29 |
| Rate for Payer: Aetna Commercial |
$12.59
|
| Rate for Payer: Humana Medicare Advantage |
$5.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.60
|
| Rate for Payer: WPPA Medicare Advantage |
$8.39
|
|
|
polyethylene glycol 3350 Oral Pwdr for Recon 238 g [HMC]
|
Facility
|
OP
|
$13.99
|
|
|
Service Code
|
NDC 00904602577
|
| Hospital Charge Code |
3800029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$13.29 |
| Rate for Payer: Aetna Commercial |
$12.59
|
| Rate for Payer: Humana Medicare Advantage |
$5.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.60
|
| Rate for Payer: WPPA Medicare Advantage |
$8.39
|
|
|
polyethylene glycol 3350 Oral Pwdr for Recon 238 g [HMC]
|
Facility
|
IP
|
$13.99
|
|
|
Service Code
|
NDC 00536105224
|
| Hospital Charge Code |
3800029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.59 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$12.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.29
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
polyethylene glycol 3350 Oral Pwdr for Recon 238 g [HMC]
|
Facility
|
OP
|
$6.74
|
|
|
Service Code
|
NDC 51991096158
|
| Hospital Charge Code |
3800029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: Aetna Commercial |
$6.07
|
| Rate for Payer: Humana Medicare Advantage |
$2.83
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.70
|
| Rate for Payer: WPPA Medicare Advantage |
$4.04
|
|
|
polyethylene glycol 3350 Oral Pwdr for Recon 238 g [HMC]
|
Facility
|
IP
|
$13.99
|
|
|
Service Code
|
NDC 00904602577
|
| Hospital Charge Code |
3800029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.59 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$12.59
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.29
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
polyethylene glycol 3350 Oral Pwdr for Recon 238 g [HMC]
|
Facility
|
IP
|
$6.74
|
|
|
Service Code
|
NDC 51991096158
|
| Hospital Charge Code |
3800029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.07
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.40
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
polyethylene glycol 3350 Oral Pwdr for Recon [HMC]
|
Facility
|
IP
|
$25.66
|
|
|
Service Code
|
NDC 00904693176
|
| Hospital Charge Code |
3809722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.09 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$23.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.38
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
polyethylene glycol 3350 Oral Pwdr for Recon [HMC]
|
Facility
|
OP
|
$23.84
|
|
|
Service Code
|
NDC 60687043192
|
| Hospital Charge Code |
3809722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.54 |
| Max. Negotiated Rate |
$22.65 |
| Rate for Payer: Aetna Commercial |
$21.46
|
| Rate for Payer: Humana Medicare Advantage |
$10.01
|
| Rate for Payer: UnitedHealthcare Commercial |
$22.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.54
|
| Rate for Payer: WPPA Medicare Advantage |
$14.30
|
|
|
polyethylene glycol 3350 Oral Pwdr for Recon [HMC]
|
Facility
|
IP
|
$26.01
|
|
|
Service Code
|
NDC 00574041207
|
| Hospital Charge Code |
3809722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.41 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$23.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.71
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
polyethylene glycol 3350 Oral Pwdr for Recon [HMC]
|
Facility
|
OP
|
$25.66
|
|
|
Service Code
|
NDC 00904693176
|
| Hospital Charge Code |
3809722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.26 |
| Max. Negotiated Rate |
$24.38 |
| Rate for Payer: Aetna Commercial |
$23.09
|
| Rate for Payer: Humana Medicare Advantage |
$10.78
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.26
|
| Rate for Payer: WPPA Medicare Advantage |
$15.40
|
|
|
polyethylene glycol 3350 Oral Pwdr for Recon [HMC]
|
Facility
|
OP
|
$26.01
|
|
|
Service Code
|
NDC 00574041207
|
| Hospital Charge Code |
3809722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$24.71 |
| Rate for Payer: Aetna Commercial |
$23.41
|
| Rate for Payer: Humana Medicare Advantage |
$10.92
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.40
|
| Rate for Payer: WPPA Medicare Advantage |
$15.61
|
|
|
polyethylene glycol 3350 Oral Pwdr for Recon [HMC]
|
Facility
|
IP
|
$23.84
|
|
|
Service Code
|
NDC 60687043192
|
| Hospital Charge Code |
3809722
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.46 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$21.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$22.65
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
POLYP SUCTION TRAP
|
Facility
|
OP
|
$35.00
|
|
| Hospital Charge Code |
3257615
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$33.25 |
| Rate for Payer: Aetna Commercial |
$31.50
|
| Rate for Payer: Humana Medicare Advantage |
$14.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.00
|
| Rate for Payer: WPPA Medicare Advantage |
$21.00
|
|
|
POLYP SUCTION TRAP
|
Facility
|
IP
|
$35.00
|
|
| Hospital Charge Code |
3257615
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$31.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.25
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Porphyrins, Total Plasma QST
|
Facility
|
OP
|
$165.00
|
|
|
Service Code
|
HCPCS 82542
|
| Hospital Charge Code |
3552185
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$194.29 |
| Rate for Payer: Aetna Commercial |
$148.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$194.29
|
| Rate for Payer: Humana Medicare Advantage |
$69.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.48
|
| Rate for Payer: WPPA Medicare Advantage |
$99.00
|
|
|
Porphyrins, Total Plasma QST
|
Facility
|
IP
|
$165.00
|
|
|
Service Code
|
HCPCS 82542
|
| Hospital Charge Code |
3552185
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$148.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$148.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$156.75
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Port-A-Cath Guide Hi-Wire
|
Facility
|
IP
|
$129.00
|
|
| Hospital Charge Code |
3251048
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$116.10 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$122.55
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Port-A-Cath Guide Hi-Wire
|
Facility
|
OP
|
$129.00
|
|
| Hospital Charge Code |
3251048
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$122.55 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Humana Medicare Advantage |
$54.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$122.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.60
|
| Rate for Payer: WPPA Medicare Advantage |
$77.40
|
|
|
Port PowerPort ClearVUE ISP w/smooth Septum 8fr ChronoFlex Catheter Intermediate Kit
|
Facility
|
OP
|
$900.00
|
|
| Hospital Charge Code |
3251044
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$855.00 |
| Rate for Payer: Aetna Commercial |
$810.00
|
| Rate for Payer: Humana Medicare Advantage |
$378.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$855.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$360.00
|
| Rate for Payer: WPPA Medicare Advantage |
$540.00
|
|
|
Port PowerPort ClearVUE ISP w/smooth Septum 8fr ChronoFlex Catheter Intermediate Kit
|
Facility
|
IP
|
$900.00
|
|
| Hospital Charge Code |
3251044
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$810.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$810.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$855.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Port PowerPort ClearVUE Slim w/smooth Septum 8fr ChronoFlex Catheter Intermediate Kit (Bard Peripher
|
Facility
|
IP
|
$381.60
|
|
| Hospital Charge Code |
3251046
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$343.44 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$343.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$362.52
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Port PowerPort ClearVUE Slim w/smooth Septum 8fr ChronoFlex Catheter Intermediate Kit (Bard Peripher
|
Facility
|
OP
|
$381.60
|
|
| Hospital Charge Code |
3251046
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$152.64 |
| Max. Negotiated Rate |
$362.52 |
| Rate for Payer: Aetna Commercial |
$343.44
|
| Rate for Payer: Humana Medicare Advantage |
$160.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$362.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$152.64
|
| Rate for Payer: WPPA Medicare Advantage |
$228.96
|
|
