|
Rituxan Sensitivity (CD20) QST
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
HCPCS 86356
|
| Hospital Charge Code |
3550981
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.76 |
| Max. Negotiated Rate |
$143.45 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$50.96
|
| Rate for Payer: Humana Medicare Advantage |
$63.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$143.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.76
|
| Rate for Payer: WPPA Medicare Advantage |
$90.60
|
|
|
riTUXimab 10 mg/mL IV Sol 50 mL [HMC]
|
Facility
|
IP
|
$9,864.96
|
|
|
Service Code
|
HCPCS J9312
|
| Hospital Charge Code |
3850545
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$9,371.71 |
| Rate for Payer: Aetna Commercial |
$8,878.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$9,371.71
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
riTUXimab 10 mg/mL IV Sol 50 mL [HMC]
|
Facility
|
OP
|
$9,864.96
|
|
|
Service Code
|
HCPCS J9312
|
| Hospital Charge Code |
3850545
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.77 |
| Max. Negotiated Rate |
$9,371.71 |
| Rate for Payer: Aetna Commercial |
$8,878.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$97.04
|
| Rate for Payer: Humana Medicare Advantage |
$4,143.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$9,371.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$74.77
|
| Rate for Payer: WPPA Medicare Advantage |
$5,918.98
|
|
|
riTUXimab 10 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$1,701.14
|
|
|
Service Code
|
HCPCS J9312
|
| Hospital Charge Code |
3850552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.77 |
| Max. Negotiated Rate |
$1,616.08 |
| Rate for Payer: Aetna Commercial |
$1,531.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$97.04
|
| Rate for Payer: Humana Medicare Advantage |
$714.48
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,616.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$74.77
|
| Rate for Payer: WPPA Medicare Advantage |
$1,020.68
|
|
|
riTUXimab 10 mg/mL IV Sol [HMC]
|
Facility
|
IP
|
$1,701.14
|
|
|
Service Code
|
HCPCS J9312
|
| Hospital Charge Code |
3850552
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$1,616.08 |
| Rate for Payer: Aetna Commercial |
$1,531.03
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,616.08
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
riTUXimab abbs 10 mg/mL Sol
|
Facility
|
OP
|
$8,878.27
|
|
|
Service Code
|
HCPCS Q5115
|
| Hospital Charge Code |
3850553
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.15 |
| Max. Negotiated Rate |
$8,434.36 |
| Rate for Payer: Aetna Commercial |
$7,990.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$41.59
|
| Rate for Payer: Humana Medicare Advantage |
$3,728.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$8,434.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.15
|
| Rate for Payer: WPPA Medicare Advantage |
$5,326.96
|
|
|
riTUXimab abbs 10 mg/mL Sol
|
Facility
|
IP
|
$8,878.27
|
|
|
Service Code
|
HCPCS Q5115
|
| Hospital Charge Code |
3850553
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$8,434.36 |
| Rate for Payer: Aetna Commercial |
$7,990.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$8,434.36
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
riTUXimab-pvvr 10 mg/mL Sol 50 mL [HMC]
|
Facility
|
IP
|
$8,601.60
|
|
|
Service Code
|
HCPCS Q5119
|
| Hospital Charge Code |
3850546
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$8,171.52 |
| Rate for Payer: Aetna Commercial |
$7,741.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$8,171.52
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
riTUXimab-pvvr 10 mg/mL Sol 50 mL [HMC]
|
Facility
|
OP
|
$8,601.60
|
|
|
Service Code
|
HCPCS Q5119
|
| Hospital Charge Code |
3850546
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.27 |
| Max. Negotiated Rate |
$8,171.52 |
| Rate for Payer: Aetna Commercial |
$7,741.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$27.44
|
| Rate for Payer: Humana Medicare Advantage |
$3,612.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$8,171.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.27
|
| Rate for Payer: WPPA Medicare Advantage |
$5,160.96
|
|
|
rivaroxaban 10 mg Tab [HMC]
|
Facility
|
OP
|
$27.78
|
|
|
Service Code
|
NDC 50458058010
|
| Hospital Charge Code |
3800942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.11 |
| Max. Negotiated Rate |
$26.39 |
| Rate for Payer: Aetna Commercial |
$25.00
|
| Rate for Payer: Humana Medicare Advantage |
$11.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.11
|
| Rate for Payer: WPPA Medicare Advantage |
$16.67
|
|
|
rivaroxaban 10 mg Tab [HMC]
|
Facility
|
OP
|
$27.78
|
|
|
Service Code
|
NDC 50458058030
|
| Hospital Charge Code |
3800942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.11 |
| Max. Negotiated Rate |
$26.39 |
| Rate for Payer: Aetna Commercial |
$25.00
|
| Rate for Payer: Humana Medicare Advantage |
$11.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.11
|
| Rate for Payer: WPPA Medicare Advantage |
$16.67
|
|
|
rivaroxaban 10 mg Tab [HMC]
|
Facility
|
IP
|
$27.78
|
|
|
Service Code
|
NDC 50458058030
|
| Hospital Charge Code |
3800942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.39
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
rivaroxaban 10 mg Tab [HMC]
|
Facility
|
IP
|
$27.78
|
|
|
Service Code
|
NDC 50458058010
|
| Hospital Charge Code |
3800942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.39
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
rivaroxaban 2.5 mg Tab [HMC]
|
Facility
|
OP
|
$27.78
|
|
|
Service Code
|
NDC 50458057760
|
| Hospital Charge Code |
3800921
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.11 |
| Max. Negotiated Rate |
$26.39 |
| Rate for Payer: Aetna Commercial |
$25.00
|
| Rate for Payer: Humana Medicare Advantage |
$11.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.11
|
| Rate for Payer: WPPA Medicare Advantage |
$16.67
|
|
|
rivaroxaban 2.5 mg Tab [HMC]
|
Facility
|
IP
|
$27.78
|
|
|
Service Code
|
NDC 50458057760
|
| Hospital Charge Code |
3800921
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.39
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
rivastigmine 13.3 mg/24 hr [HMC]
|
Facility
|
OP
|
$32.43
|
|
|
Service Code
|
NDC 00078050361
|
| Hospital Charge Code |
3800172
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.97 |
| Max. Negotiated Rate |
$30.81 |
| Rate for Payer: Aetna Commercial |
$29.19
|
| Rate for Payer: Humana Medicare Advantage |
$13.62
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.97
|
| Rate for Payer: WPPA Medicare Advantage |
$19.46
|
|
|
rivastigmine 13.3 mg/24 hr [HMC]
|
Facility
|
IP
|
$38.79
|
|
|
Service Code
|
NDC 65162074934
|
| Hospital Charge Code |
3800172
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.91 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$34.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.85
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
rivastigmine 13.3 mg/24 hr [HMC]
|
Facility
|
OP
|
$38.79
|
|
|
Service Code
|
NDC 00781731331
|
| Hospital Charge Code |
3800172
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.52 |
| Max. Negotiated Rate |
$36.85 |
| Rate for Payer: Aetna Commercial |
$34.91
|
| Rate for Payer: Humana Medicare Advantage |
$16.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.52
|
| Rate for Payer: WPPA Medicare Advantage |
$23.27
|
|
|
rivastigmine 13.3 mg/24 hr [HMC]
|
Facility
|
OP
|
$38.79
|
|
|
Service Code
|
NDC 65162074934
|
| Hospital Charge Code |
3800172
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.52 |
| Max. Negotiated Rate |
$36.85 |
| Rate for Payer: Aetna Commercial |
$34.91
|
| Rate for Payer: Humana Medicare Advantage |
$16.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.52
|
| Rate for Payer: WPPA Medicare Advantage |
$23.27
|
|
|
rivastigmine 13.3 mg/24 hr [HMC]
|
Facility
|
IP
|
$38.79
|
|
|
Service Code
|
NDC 00781731331
|
| Hospital Charge Code |
3800172
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.91 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$34.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.85
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
rivastigmine 13.3 mg/24 hr [HMC]
|
Facility
|
IP
|
$32.43
|
|
|
Service Code
|
NDC 00078050361
|
| Hospital Charge Code |
3800172
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.19 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$29.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.81
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
rivastigmine 1.5 mg Cap [HMC]
|
Facility
|
IP
|
$18.98
|
|
|
Service Code
|
NDC 65862064860
|
| Hospital Charge Code |
3808876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.08 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$17.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.03
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
rivastigmine 1.5 mg Cap [HMC]
|
Facility
|
IP
|
$18.98
|
|
|
Service Code
|
NDC 51991079306
|
| Hospital Charge Code |
3808876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.08 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$17.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.03
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
rivastigmine 1.5 mg Cap [HMC]
|
Facility
|
OP
|
$18.98
|
|
|
Service Code
|
NDC 65862064860
|
| Hospital Charge Code |
3808876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.59 |
| Max. Negotiated Rate |
$18.03 |
| Rate for Payer: Aetna Commercial |
$17.08
|
| Rate for Payer: Humana Medicare Advantage |
$7.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.59
|
| Rate for Payer: WPPA Medicare Advantage |
$11.39
|
|
|
rivastigmine 1.5 mg Cap [HMC]
|
Facility
|
OP
|
$18.98
|
|
|
Service Code
|
NDC 51991079306
|
| Hospital Charge Code |
3808876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.59 |
| Max. Negotiated Rate |
$18.03 |
| Rate for Payer: Aetna Commercial |
$17.08
|
| Rate for Payer: Humana Medicare Advantage |
$7.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.59
|
| Rate for Payer: WPPA Medicare Advantage |
$11.39
|
|
