|
prazosin 5 mg Cap [HMC]
|
Facility
|
IP
|
$17.92
|
|
|
Service Code
|
NDC 51079063220
|
| Hospital Charge Code |
3807382
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.13 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$16.13
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.02
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Prealbumin QST
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS 84134
|
| Hospital Charge Code |
3552268
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.90 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$76.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Prealbumin QST
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
HCPCS 84134
|
| Hospital Charge Code |
3552268
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$48.81
|
| Rate for Payer: Humana Medicare Advantage |
$34.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$76.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.40
|
| Rate for Payer: WPPA Medicare Advantage |
$48.60
|
|
|
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC
|
Facility
|
IP
|
$6,639.93
|
|
|
Service Code
|
MSDRG 067
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$6,639.93 |
| Rate for Payer: UnitedHealthcare Medicaid |
$6,639.93
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC
|
Facility
|
IP
|
$3,907.71
|
|
|
Service Code
|
MSDRG 068
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$3,907.71 |
| Rate for Payer: UnitedHealthcare Medicaid |
$3,907.71
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
prednisoLONE ophthalmic acetate 1% Sus [HMC]
|
Facility
|
OP
|
$94.68
|
|
|
Service Code
|
NDC 61314063705
|
| Hospital Charge Code |
3800922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.87 |
| Max. Negotiated Rate |
$89.95 |
| Rate for Payer: Aetna Commercial |
$85.21
|
| Rate for Payer: Humana Medicare Advantage |
$39.77
|
| Rate for Payer: UnitedHealthcare Commercial |
$89.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.87
|
| Rate for Payer: WPPA Medicare Advantage |
$56.81
|
|
|
prednisoLONE ophthalmic acetate 1% Sus [HMC]
|
Facility
|
IP
|
$94.68
|
|
|
Service Code
|
NDC 61314063705
|
| Hospital Charge Code |
3800922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.21 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$85.21
|
| Rate for Payer: UnitedHealthcare Commercial |
$89.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
prednisoLONE sodium phosphate 15 mg/5 mL Oral Liq [HMC]
|
Facility
|
IP
|
$13.12
|
|
|
Service Code
|
HCPCS J7510
|
| Hospital Charge Code |
3800923
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.81 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$11.81
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.46
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
prednisoLONE sodium phosphate 15 mg/5 mL Oral Liq [HMC]
|
Facility
|
OP
|
$13.12
|
|
|
Service Code
|
HCPCS J7510
|
| Hospital Charge Code |
3800923
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$12.46 |
| Rate for Payer: Aetna Commercial |
$11.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.37
|
| Rate for Payer: Humana Medicare Advantage |
$5.51
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.25
|
| Rate for Payer: WPPA Medicare Advantage |
$7.87
|
|
|
predniSONE 20 mg Tab [HMC]
|
Facility
|
OP
|
$9.50
|
|
|
Service Code
|
HCPCS J7512
|
| Hospital Charge Code |
3806004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$9.03 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Commercial |
$5.20
|
| Rate for Payer: Aetna Commercial |
$5.14
|
| Rate for Payer: Aetna Commercial |
$5.26
|
| Rate for Payer: Aetna Commercial |
$5.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.01
|
| Rate for Payer: Humana Medicare Advantage |
$2.36
|
| Rate for Payer: Humana Medicare Advantage |
$2.40
|
| Rate for Payer: Humana Medicare Advantage |
$2.46
|
| Rate for Payer: Humana Medicare Advantage |
$3.99
|
| Rate for Payer: Humana Medicare Advantage |
$2.43
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.49
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.03
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.33
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.80
|
| Rate for Payer: WPPA Medicare Advantage |
$3.51
|
| Rate for Payer: WPPA Medicare Advantage |
$3.43
|
| Rate for Payer: WPPA Medicare Advantage |
$3.37
|
| Rate for Payer: WPPA Medicare Advantage |
$5.70
|
| Rate for Payer: WPPA Medicare Advantage |
$3.47
|
|
|
predniSONE 20 mg Tab [HMC]
|
Facility
|
IP
|
$5.78
|
|
|
Service Code
|
HCPCS J7512
|
| Hospital Charge Code |
3806004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.20
|
| Rate for Payer: Aetna Commercial |
$5.05
|
| Rate for Payer: Aetna Commercial |
$5.14
|
| Rate for Payer: Aetna Commercial |
$5.26
|
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.33
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.49
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.03
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.56
|
| 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
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
predniSONE 5 mg Tab [HMC]
|
Facility
|
IP
|
$5.60
|
|
|
Service Code
|
HCPCS J7512
|
| Hospital Charge Code |
3808496
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.04 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.04
|
| Rate for Payer: Aetna Commercial |
$5.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.32
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
predniSONE 5 mg Tab [HMC]
|
Facility
|
OP
|
$5.75
|
|
|
Service Code
|
HCPCS J7512
|
| Hospital Charge Code |
3808496
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$5.46 |
| Rate for Payer: Aetna Commercial |
$5.17
|
| Rate for Payer: Aetna Commercial |
$5.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.01
|
| Rate for Payer: Humana Medicare Advantage |
$2.42
|
| Rate for Payer: Humana Medicare Advantage |
$2.35
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.30
|
| Rate for Payer: WPPA Medicare Advantage |
$3.45
|
| Rate for Payer: WPPA Medicare Advantage |
$3.36
|
|
|
pregabalin 100 mg oral capsule [HMC]
|
Facility
|
IP
|
$26.07
|
|
|
Service Code
|
NDC 69238131309
|
| Hospital Charge Code |
3800729
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.46 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$23.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.77
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
pregabalin 100 mg oral capsule [HMC]
|
Facility
|
IP
|
$26.07
|
|
|
Service Code
|
NDC 43598029490
|
| Hospital Charge Code |
3800729
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.46 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$23.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.77
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
pregabalin 100 mg oral capsule [HMC]
|
Facility
|
OP
|
$8.02
|
|
|
Service Code
|
NDC 00904700161
|
| Hospital Charge Code |
3800729
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$7.62 |
| Rate for Payer: Aetna Commercial |
$7.22
|
| Rate for Payer: Humana Medicare Advantage |
$3.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.21
|
| Rate for Payer: WPPA Medicare Advantage |
$4.81
|
|
|
pregabalin 100 mg oral capsule [HMC]
|
Facility
|
OP
|
$26.07
|
|
|
Service Code
|
NDC 69238131309
|
| Hospital Charge Code |
3800729
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$24.77 |
| Rate for Payer: Aetna Commercial |
$23.46
|
| Rate for Payer: Humana Medicare Advantage |
$10.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.43
|
| Rate for Payer: WPPA Medicare Advantage |
$15.64
|
|
|
pregabalin 100 mg oral capsule [HMC]
|
Facility
|
OP
|
$26.07
|
|
|
Service Code
|
NDC 43598029490
|
| Hospital Charge Code |
3800729
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$24.77 |
| Rate for Payer: Aetna Commercial |
$23.46
|
| Rate for Payer: Humana Medicare Advantage |
$10.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$24.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.43
|
| Rate for Payer: WPPA Medicare Advantage |
$15.64
|
|
|
pregabalin 100 mg oral capsule [HMC]
|
Facility
|
IP
|
$8.02
|
|
|
Service Code
|
NDC 00904700161
|
| Hospital Charge Code |
3800729
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.22 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.22
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.62
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
pregabalin 25 mg oral capsule [HMC]
|
Facility
|
IP
|
$28.13
|
|
|
Service Code
|
NDC 00071101268
|
| Hospital Charge Code |
3800229
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.32 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.72
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
pregabalin 25 mg oral capsule [HMC]
|
Facility
|
OP
|
$7.79
|
|
|
Service Code
|
NDC 00904699161
|
| Hospital Charge Code |
3800229
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Humana Medicare Advantage |
$3.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.12
|
| Rate for Payer: WPPA Medicare Advantage |
$4.67
|
|
|
pregabalin 25 mg oral capsule [HMC]
|
Facility
|
OP
|
$9.85
|
|
|
Service Code
|
NDC 60687047301
|
| Hospital Charge Code |
3800229
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.94 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Aetna Commercial |
$8.87
|
| Rate for Payer: Humana Medicare Advantage |
$4.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.94
|
| Rate for Payer: WPPA Medicare Advantage |
$5.91
|
|
|
pregabalin 25 mg oral capsule [HMC]
|
Facility
|
IP
|
$9.85
|
|
|
Service Code
|
NDC 60687047301
|
| Hospital Charge Code |
3800229
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$9.36
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
pregabalin 25 mg oral capsule [HMC]
|
Facility
|
IP
|
$7.79
|
|
|
Service Code
|
NDC 00904699161
|
| Hospital Charge Code |
3800229
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.01 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.40
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
pregabalin 25 mg oral capsule [HMC]
|
Facility
|
OP
|
$28.13
|
|
|
Service Code
|
NDC 00071101268
|
| Hospital Charge Code |
3800229
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.25 |
| Max. Negotiated Rate |
$26.72 |
| Rate for Payer: Aetna Commercial |
$25.32
|
| Rate for Payer: Humana Medicare Advantage |
$11.81
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.25
|
| Rate for Payer: WPPA Medicare Advantage |
$16.88
|
|
