|
Q3014 ED TELEHEALTH FACILITY FEE TechFee
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
3300425
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$22.88 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$38.38
|
| Rate for Payer: Humana Medicare Advantage |
$83.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$188.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.88
|
| Rate for Payer: WPPA Medicare Advantage |
$118.80
|
|
|
Q3014 ED TELEHEALTH FACILITY FEE TechFee
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
3300425
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$178.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$188.10
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Q3014 Telehealth Facility Fee
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
3350250
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$170.10 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$170.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$179.55
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Q3014 Telehealth Facility Fee
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
3350250
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$22.88 |
| Max. Negotiated Rate |
$179.55 |
| Rate for Payer: Aetna Commercial |
$170.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$38.38
|
| Rate for Payer: Humana Medicare Advantage |
$79.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$179.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.88
|
| Rate for Payer: WPPA Medicare Advantage |
$113.40
|
|
|
Q3014 Telehealth Facility Fee CCMC
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
3353014
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$22.88 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$38.38
|
| Rate for Payer: Humana Medicare Advantage |
$83.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$188.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.88
|
| Rate for Payer: WPPA Medicare Advantage |
$118.80
|
|
|
Q3014 Telehealth Facility Fee CCMC
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
3353014
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$178.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$178.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$188.10
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Qnatal(Tm) Advanced QST
|
Facility
|
OP
|
$4,741.00
|
|
|
Service Code
|
HCPCS 81420
|
| Hospital Charge Code |
3551421
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$671.00 |
| Max. Negotiated Rate |
$4,503.95 |
| Rate for Payer: Aetna Commercial |
$4,266.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$2,300.78
|
| Rate for Payer: Humana Medicare Advantage |
$1,991.22
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,503.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$671.00
|
| Rate for Payer: WPPA Medicare Advantage |
$2,844.60
|
|
|
Qnatal(Tm) Advanced QST
|
Facility
|
IP
|
$4,741.00
|
|
|
Service Code
|
HCPCS 81420
|
| Hospital Charge Code |
3551421
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,503.95 |
| Rate for Payer: Aetna Commercial |
$4,266.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,503.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Quad Screen QST
|
Facility
|
IP
|
$366.00
|
|
|
Service Code
|
HCPCS 81511
|
| Hospital Charge Code |
3551511
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$329.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$329.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$347.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Quad Screen QST
|
Facility
|
OP
|
$366.00
|
|
|
Service Code
|
HCPCS 81511
|
| Hospital Charge Code |
3551511
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$146.40 |
| Max. Negotiated Rate |
$347.70 |
| Rate for Payer: Aetna Commercial |
$329.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$215.31
|
| Rate for Payer: Humana Medicare Advantage |
$153.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$347.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$146.40
|
| Rate for Payer: WPPA Medicare Advantage |
$219.60
|
|
|
Quantiferon TB Gold Plus, 4T, Incubated
|
Facility
|
OP
|
$444.00
|
|
|
Service Code
|
HCPCS 86480
|
| Hospital Charge Code |
3550076
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.98 |
| Max. Negotiated Rate |
$421.80 |
| Rate for Payer: Aetna Commercial |
$399.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$133.00
|
| Rate for Payer: Humana Medicare Advantage |
$186.48
|
| Rate for Payer: UnitedHealthcare Commercial |
$421.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$61.98
|
| Rate for Payer: WPPA Medicare Advantage |
$266.40
|
|
|
Quantiferon TB Gold Plus, 4T, Incubated
|
Facility
|
IP
|
$444.00
|
|
|
Service Code
|
HCPCS 86480
|
| Hospital Charge Code |
3550076
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$399.60 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$399.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$421.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Quantiferon TB Gold Plus, 4T, Incubated QST
|
Facility
|
IP
|
$444.00
|
|
|
Service Code
|
HCPCS 86480
|
| Hospital Charge Code |
3550076
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$399.60 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$399.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$421.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Quantiferon TB Gold Plus, 4T, Incubated QST
|
Facility
|
OP
|
$444.00
|
|
|
Service Code
|
HCPCS 86480
|
| Hospital Charge Code |
3550076
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.98 |
| Max. Negotiated Rate |
$421.80 |
| Rate for Payer: Aetna Commercial |
$399.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$133.00
|
| Rate for Payer: Humana Medicare Advantage |
$186.48
|
| Rate for Payer: UnitedHealthcare Commercial |
$421.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$61.98
|
| Rate for Payer: WPPA Medicare Advantage |
$266.40
|
|
|
Quest AD-Detect(R) Apolipoprotein E (ApoE) Isoform, Plasma QST
|
Facility
|
IP
|
$762.00
|
|
|
Service Code
|
HCPCS 82542
|
| Hospital Charge Code |
3552563
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$685.80 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$685.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$723.90
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Quest AD-Detect(R) Apolipoprotein E (ApoE) Isoform, Plasma QST
|
Facility
|
OP
|
$762.00
|
|
|
Service Code
|
HCPCS 82542
|
| Hospital Charge Code |
3552563
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$723.90 |
| Rate for Payer: Aetna Commercial |
$685.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$194.29
|
| Rate for Payer: Humana Medicare Advantage |
$320.04
|
| Rate for Payer: UnitedHealthcare Commercial |
$723.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.48
|
| Rate for Payer: WPPA Medicare Advantage |
$457.20
|
|
|
QUEtiapine 25 mg Tab [HMC]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 68180044501
|
| Hospital Charge Code |
3802465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$16.14 |
| Rate for Payer: Aetna Commercial |
$15.29
|
| Rate for Payer: Humana Medicare Advantage |
$7.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.80
|
| Rate for Payer: WPPA Medicare Advantage |
$10.19
|
|
|
QUEtiapine 25 mg Tab [HMC]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 68180044501
|
| Hospital Charge Code |
3802465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$15.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.14
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
QUEtiapine 25 mg Tab [HMC]
|
Facility
|
IP
|
$6.04
|
|
|
Service Code
|
NDC 00904663861
|
| Hospital Charge Code |
3802465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.44 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.74
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
QUEtiapine 25 mg Tab [HMC]
|
Facility
|
OP
|
$6.04
|
|
|
Service Code
|
NDC 00904663861
|
| Hospital Charge Code |
3802465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.44
|
| Rate for Payer: Humana Medicare Advantage |
$2.54
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.42
|
| Rate for Payer: WPPA Medicare Advantage |
$3.62
|
|
|
QUEtiapine 50 mg oral tablet [HMC]
|
Facility
|
IP
|
$21.42
|
|
|
Service Code
|
NDC 47335090388
|
| Hospital Charge Code |
3807006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.28 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$19.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
QUEtiapine 50 mg oral tablet [HMC]
|
Facility
|
OP
|
$21.42
|
|
|
Service Code
|
NDC 68001018000
|
| Hospital Charge Code |
3807006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.57 |
| Max. Negotiated Rate |
$20.35 |
| Rate for Payer: Aetna Commercial |
$19.28
|
| Rate for Payer: Humana Medicare Advantage |
$9.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.57
|
| Rate for Payer: WPPA Medicare Advantage |
$12.85
|
|
|
QUEtiapine 50 mg oral tablet [HMC]
|
Facility
|
IP
|
$21.42
|
|
|
Service Code
|
NDC 68001018000
|
| Hospital Charge Code |
3807006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.28 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$19.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
QUEtiapine 50 mg oral tablet [HMC]
|
Facility
|
OP
|
$21.42
|
|
|
Service Code
|
NDC 47335090388
|
| Hospital Charge Code |
3807006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.57 |
| Max. Negotiated Rate |
$20.35 |
| Rate for Payer: Aetna Commercial |
$19.28
|
| Rate for Payer: Humana Medicare Advantage |
$9.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.57
|
| Rate for Payer: WPPA Medicare Advantage |
$12.85
|
|
|
QUEtiapine 50 mg oral tablet [HMC]
|
Facility
|
IP
|
$21.42
|
|
|
Service Code
|
NDC 67877024901
|
| Hospital Charge Code |
3807006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.28 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$19.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
