|
Shoe Leveler EvenUp Medium Women's 9-11 Men's 8.5-10.5
|
Facility
|
OP
|
$126.00
|
|
| Hospital Charge Code |
3259940
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$50.40 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna Commercial |
$113.40
|
| Rate for Payer: Humana Medicare Advantage |
$52.92
|
| Rate for Payer: UnitedHealthcare Commercial |
$119.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.40
|
| Rate for Payer: WPPA Medicare Advantage |
$75.60
|
|
|
Shoe Leveler EvenUp Medium Women's 9-11 Men's 8.5-10.5
|
Facility
|
IP
|
$126.00
|
|
| Hospital Charge Code |
3259940
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$113.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$113.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$119.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC
|
Facility
|
IP
|
$7,878.96
|
|
|
Service Code
|
MSDRG 511
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$7,878.96 |
| Rate for Payer: UnitedHealthcare Medicaid |
$7,878.96
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC
|
Facility
|
IP
|
$11,437.20
|
|
|
Service Code
|
MSDRG 510
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$11,437.20 |
| Rate for Payer: UnitedHealthcare Medicaid |
$11,437.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$6,258.69
|
|
|
Service Code
|
MSDRG 512
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$6,258.69 |
| Rate for Payer: UnitedHealthcare Medicaid |
$6,258.69
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Shrimp (F24) IgE QST
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
3552828
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$15.51
|
| Rate for Payer: Humana Medicare Advantage |
$8.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.22
|
| Rate for Payer: WPPA Medicare Advantage |
$12.60
|
|
|
Shrimp (F24) IgE QST
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
3552828
|
|
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
|
|
|
SI Belt Aspen Evergreen 621 Sacroiliac Belt Size Medium
|
Facility
|
OP
|
$257.00
|
|
| Hospital Charge Code |
3259820
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$102.80 |
| Max. Negotiated Rate |
$244.15 |
| Rate for Payer: Aetna Commercial |
$231.30
|
| Rate for Payer: Humana Medicare Advantage |
$107.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$244.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$102.80
|
| Rate for Payer: WPPA Medicare Advantage |
$154.20
|
|
|
SI Belt Aspen Evergreen 621 Sacroiliac Belt Size Medium
|
Facility
|
IP
|
$257.00
|
|
| Hospital Charge Code |
3259820
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$231.30 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$231.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$244.15
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Sickle Cell Scr QST
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS 85660
|
| Hospital Charge Code |
3555660
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$21.85
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Sickle Cell Scr QST
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS 85660
|
| Hospital Charge Code |
3555660
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$21.85 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$14.33
|
| Rate for Payer: Humana Medicare Advantage |
$9.66
|
| Rate for Payer: UnitedHealthcare Commercial |
$21.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.68
|
| Rate for Payer: WPPA Medicare Advantage |
$13.80
|
|
|
Sigmoidoscopy and Biopsy HMC
|
Facility
|
OP
|
$1,523.00
|
|
|
Service Code
|
HCPCS 45331
|
| Hospital Charge Code |
3150438
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$296.08 |
| Max. Negotiated Rate |
$1,446.85 |
| Rate for Payer: Aetna Commercial |
$1,370.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$808.00
|
| Rate for Payer: Humana Medicare Advantage |
$639.66
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,446.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$296.08
|
| Rate for Payer: WPPA Medicare Advantage |
$913.80
|
|
|
Sigmoidoscopy and Biopsy HMC
|
Facility
|
IP
|
$1,523.00
|
|
|
Service Code
|
HCPCS 45331
|
| Hospital Charge Code |
3150438
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$1,446.85 |
| Rate for Payer: Aetna Commercial |
$1,370.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,446.85
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC
|
Facility
|
IP
|
$8,101.35
|
|
|
Service Code
|
MSDRG 555
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$8,101.35 |
| Rate for Payer: UnitedHealthcare Medicaid |
$8,101.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC
|
Facility
|
IP
|
$5,083.20
|
|
|
Service Code
|
MSDRG 556
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$5,083.20 |
| Rate for Payer: UnitedHealthcare Medicaid |
$5,083.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SIGNS AND SYMPTOMS WITH MCC
|
Facility
|
IP
|
$7,529.49
|
|
|
Service Code
|
MSDRG 947
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$7,529.49 |
| Rate for Payer: UnitedHealthcare Medicaid |
$7,529.49
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SIGNS AND SYMPTOMS WITHOUT MCC
|
Facility
|
IP
|
$7,116.48
|
|
|
Service Code
|
MSDRG 948
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$7,116.48 |
| Rate for Payer: UnitedHealthcare Medicaid |
$7,116.48
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
sildenafil 20 mg oral tablet [HMC]
|
Facility
|
IP
|
$9.18
|
|
|
Service Code
|
NDC 00904667104
|
| Hospital Charge Code |
3800385
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.26 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$8.26
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.72
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
sildenafil 20 mg oral tablet [HMC]
|
Facility
|
OP
|
$6.82
|
|
|
Service Code
|
NDC 63739007233
|
| Hospital Charge Code |
3800385
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: Aetna Commercial |
$6.14
|
| Rate for Payer: Humana Medicare Advantage |
$2.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.73
|
| Rate for Payer: WPPA Medicare Advantage |
$4.09
|
|
|
sildenafil 20 mg oral tablet [HMC]
|
Facility
|
IP
|
$27.05
|
|
|
Service Code
|
NDC 00093551798
|
| Hospital Charge Code |
3800385
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.34 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$24.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$25.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
sildenafil 20 mg oral tablet [HMC]
|
Facility
|
OP
|
$9.18
|
|
|
Service Code
|
NDC 00904667104
|
| Hospital Charge Code |
3800385
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$8.72 |
| Rate for Payer: Aetna Commercial |
$8.26
|
| Rate for Payer: Humana Medicare Advantage |
$3.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.67
|
| Rate for Payer: WPPA Medicare Advantage |
$5.51
|
|
|
sildenafil 20 mg oral tablet [HMC]
|
Facility
|
IP
|
$6.82
|
|
|
Service Code
|
NDC 63739007233
|
| Hospital Charge Code |
3800385
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.48
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
sildenafil 20 mg oral tablet [HMC]
|
Facility
|
OP
|
$27.05
|
|
|
Service Code
|
NDC 00093551798
|
| Hospital Charge Code |
3800385
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$25.70 |
| Rate for Payer: Aetna Commercial |
$24.34
|
| Rate for Payer: Humana Medicare Advantage |
$11.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$25.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.82
|
| Rate for Payer: WPPA Medicare Advantage |
$16.23
|
|
|
silodosin 4 mg Cap [HMC]
|
Facility
|
OP
|
$27.41
|
|
|
Service Code
|
NDC 33342038407
|
| Hospital Charge Code |
3800417
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.96 |
| Max. Negotiated Rate |
$26.04 |
| Rate for Payer: Aetna Commercial |
$24.67
|
| Rate for Payer: Humana Medicare Advantage |
$11.51
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.96
|
| Rate for Payer: WPPA Medicare Advantage |
$16.45
|
|
|
silodosin 4 mg Cap [HMC]
|
Facility
|
IP
|
$27.41
|
|
|
Service Code
|
NDC 33342038407
|
| Hospital Charge Code |
3800417
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.67 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$24.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.04
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
