|
Potato (f35) IgE QST
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
3552823
|
|
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
|
|
|
Pouch Specimen Retrieval Bag (Endo Catch Gold) (Endopouch)(EndoCatch II 10 mm)(Ethicon POUCH 224 ml)
|
Facility
|
IP
|
$177.21
|
|
| Hospital Charge Code |
3258290
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$159.49 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$159.49
|
| Rate for Payer: UnitedHealthcare Commercial |
$168.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Pouch Specimen Retrieval Bag (Endo Catch Gold) (Endopouch)(EndoCatch II 10 mm)(Ethicon POUCH 224 ml)
|
Facility
|
OP
|
$177.21
|
|
| Hospital Charge Code |
3258290
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$70.88 |
| Max. Negotiated Rate |
$168.35 |
| Rate for Payer: Aetna Commercial |
$159.49
|
| Rate for Payer: Humana Medicare Advantage |
$74.43
|
| Rate for Payer: UnitedHealthcare Commercial |
$168.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$70.88
|
| Rate for Payer: WPPA Medicare Advantage |
$106.33
|
|
|
Pouch Specimen Retrieval Bag (Endo Cath Gold) (Endopouch)(EndoCatch II 15 mm)
|
Facility
|
OP
|
$297.50
|
|
| Hospital Charge Code |
3258292
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$282.62 |
| Rate for Payer: Aetna Commercial |
$267.75
|
| Rate for Payer: Humana Medicare Advantage |
$124.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$282.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$119.00
|
| Rate for Payer: WPPA Medicare Advantage |
$178.50
|
|
|
Pouch Specimen Retrieval Bag (Endo Cath Gold) (Endopouch)(EndoCatch II 15 mm)
|
Facility
|
IP
|
$297.50
|
|
| Hospital Charge Code |
3258292
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$267.75 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$267.75
|
| Rate for Payer: UnitedHealthcare Commercial |
$282.62
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Povidone Iodine Swab (1)
|
Facility
|
IP
|
$2.50
|
|
| Hospital Charge Code |
3250227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.38
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Povidone Iodine Swab (1)
|
Facility
|
OP
|
$2.50
|
|
| Hospital Charge Code |
3250227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: Humana Medicare Advantage |
$1.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1.50
|
|
|
Povidone Iodine Swab (3)
|
Facility
|
OP
|
$2.50
|
|
| Hospital Charge Code |
3259202
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: Humana Medicare Advantage |
$1.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1.50
|
|
|
Povidone Iodine Swab (3)
|
Facility
|
IP
|
$2.50
|
|
| Hospital Charge Code |
3259202
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$2.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.38
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
povidone iodine Top 10% Sol 3840 mL [HMC]
|
Facility
|
IP
|
$78.48
|
|
|
Service Code
|
NDC 67618015001
|
| Hospital Charge Code |
3805022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.63 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$70.63
|
| Rate for Payer: UnitedHealthcare Commercial |
$74.56
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
povidone iodine Top 10% Sol 3840 mL [HMC]
|
Facility
|
OP
|
$78.48
|
|
|
Service Code
|
NDC 67618015001
|
| Hospital Charge Code |
3805022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.39 |
| Max. Negotiated Rate |
$74.56 |
| Rate for Payer: Aetna Commercial |
$70.63
|
| Rate for Payer: Humana Medicare Advantage |
$32.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$74.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.39
|
| Rate for Payer: WPPA Medicare Advantage |
$47.09
|
|
|
povidone iodine Top 10% Sol [HMC]
|
Facility
|
IP
|
$28.69
|
|
|
Service Code
|
NDC 67618015004
|
| Hospital Charge Code |
3805022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.82 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$27.26
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
povidone iodine Top 10% Sol [HMC]
|
Facility
|
OP
|
$28.69
|
|
|
Service Code
|
NDC 67618015004
|
| Hospital Charge Code |
3805022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.48 |
| Max. Negotiated Rate |
$27.26 |
| Rate for Payer: Aetna Commercial |
$25.82
|
| Rate for Payer: Humana Medicare Advantage |
$12.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$27.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.48
|
| Rate for Payer: WPPA Medicare Advantage |
$17.21
|
|
|
povidone iodine Top 10% Sol [HMC]
|
Facility
|
IP
|
$25.99
|
|
|
Service Code
|
NDC 67618015017
|
| Hospital Charge Code |
3805022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.39 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$23.39
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.69
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
povidone iodine Top 10% Sol [HMC]
|
Facility
|
OP
|
$27.44
|
|
|
Service Code
|
NDC 67618015009
|
| Hospital Charge Code |
3805022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$26.07 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Humana Medicare Advantage |
$11.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.98
|
| Rate for Payer: WPPA Medicare Advantage |
$16.46
|
|
|
povidone iodine Top 10% Sol [HMC]
|
Facility
|
IP
|
$27.44
|
|
|
Service Code
|
NDC 67618015009
|
| Hospital Charge Code |
3805022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.07
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
povidone iodine Top 10% Sol [HMC]
|
Facility
|
OP
|
$25.99
|
|
|
Service Code
|
NDC 67618015017
|
| Hospital Charge Code |
3805022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$24.69 |
| Rate for Payer: Aetna Commercial |
$23.39
|
| Rate for Payer: Humana Medicare Advantage |
$10.92
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.40
|
| Rate for Payer: WPPA Medicare Advantage |
$15.59
|
|
|
povidone iodine Top 10% Swab [HMC]
|
Facility
|
OP
|
$36.52
|
|
|
Service Code
|
NDC 52380310105
|
| Hospital Charge Code |
3250227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.61 |
| Max. Negotiated Rate |
$34.69 |
| Rate for Payer: Aetna Commercial |
$32.87
|
| Rate for Payer: Humana Medicare Advantage |
$15.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.61
|
| Rate for Payer: WPPA Medicare Advantage |
$21.91
|
|
|
povidone iodine Top 10% Swab [HMC]
|
Facility
|
IP
|
$36.52
|
|
|
Service Code
|
NDC 52380310105
|
| Hospital Charge Code |
3250227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.87 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$32.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.69
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
povidone iodine Top 10% Swab [HMC]
|
Facility
|
OP
|
$36.96
|
|
|
Service Code
|
NDC 67618015303
|
| Hospital Charge Code |
3250227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$35.11 |
| Rate for Payer: Aetna Commercial |
$33.26
|
| Rate for Payer: Humana Medicare Advantage |
$15.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.78
|
| Rate for Payer: WPPA Medicare Advantage |
$22.18
|
|
|
povidone iodine Top 10% Swab [HMC]
|
Facility
|
IP
|
$36.96
|
|
|
Service Code
|
NDC 67618015303
|
| Hospital Charge Code |
3250227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.26 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$33.26
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.11
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
PPD Administration (TB Reading) POC PIKE
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS 99212
|
| Hospital Charge Code |
3350075
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$99.75
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
PPD Administration (TB Reading) POC PIKE
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS 99212
|
| Hospital Charge Code |
3350075
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$99.75 |
| Rate for Payer: Aetna Commercial |
$94.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$85.38
|
| Rate for Payer: Humana Medicare Advantage |
$44.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$99.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.00
|
| Rate for Payer: WPPA Medicare Advantage |
$63.00
|
|
|
PPD Administration (TB Screen) POC
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
3290320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$60.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
PPD Administration (TB Screen) POC
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
3290320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$7.91 |
| Max. Negotiated Rate |
$60.80 |
| Rate for Payer: Aetna Commercial |
$57.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$18.35
|
| Rate for Payer: Humana Medicare Advantage |
$26.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$60.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.91
|
| Rate for Payer: WPPA Medicare Advantage |
$38.40
|
|
