|
SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC
|
Facility
|
IP
|
$31,801.77
|
|
|
Service Code
|
MSDRG 456
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$31,801.77 |
| Rate for Payer: UnitedHealthcare Medicaid |
$31,801.77
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC
|
Facility
|
IP
|
$16,202.70
|
|
|
Service Code
|
MSDRG 458
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$16,202.70 |
| Rate for Payer: UnitedHealthcare Medicaid |
$16,202.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Spinal Lumbar Puncture
|
Facility
|
IP
|
$736.00
|
|
|
Service Code
|
HCPCS 62272
|
| Hospital Charge Code |
3152272
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$662.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$662.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$699.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Spinal Lumbar Puncture
|
Facility
|
OP
|
$736.00
|
|
|
Service Code
|
HCPCS 62272
|
| Hospital Charge Code |
3152272
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$224.03 |
| Max. Negotiated Rate |
$699.20 |
| Rate for Payer: Aetna Commercial |
$662.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$433.29
|
| Rate for Payer: Humana Medicare Advantage |
$309.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$699.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$224.03
|
| Rate for Payer: WPPA Medicare Advantage |
$441.60
|
|
|
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS
|
Facility
|
IP
|
$12,422.07
|
|
|
Service Code
|
MSDRG 029
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$12,422.07 |
| Rate for Payer: UnitedHealthcare Medicaid |
$12,422.07
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SPINAL PROCEDURES WITH MCC
|
Facility
|
IP
|
$21,857.76
|
|
|
Service Code
|
MSDRG 028
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$21,857.76 |
| Rate for Payer: UnitedHealthcare Medicaid |
$21,857.76
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SPINAL PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$7,974.27
|
|
|
Service Code
|
MSDRG 030
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$7,974.27 |
| Rate for Payer: UnitedHealthcare Medicaid |
$7,974.27
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SpinPlus Sinus Balloon 6 x 16mm for TruDi ENT Navigation System
|
Facility
|
IP
|
$4,988.00
|
|
| Hospital Charge Code |
3259978
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$4,738.60 |
| Rate for Payer: Aetna Commercial |
$4,489.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,738.60
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SpinPlus Sinus Balloon 6 x 16mm for TruDi ENT Navigation System
|
Facility
|
OP
|
$4,988.00
|
|
| Hospital Charge Code |
3259978
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,995.20 |
| Max. Negotiated Rate |
$4,738.60 |
| Rate for Payer: Aetna Commercial |
$4,489.20
|
| Rate for Payer: Humana Medicare Advantage |
$2,094.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,738.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,995.20
|
| Rate for Payer: WPPA Medicare Advantage |
$2,992.80
|
|
|
Spirometry before & after - RT CHARGE PFT
|
Facility
|
OP
|
$443.00
|
|
|
Service Code
|
HCPCS 94060
|
| Hospital Charge Code |
3900512
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$101.68 |
| Max. Negotiated Rate |
$420.85 |
| Rate for Payer: Aetna Commercial |
$398.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$373.83
|
| Rate for Payer: Humana Medicare Advantage |
$186.06
|
| Rate for Payer: UnitedHealthcare Commercial |
$420.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$101.68
|
| Rate for Payer: WPPA Medicare Advantage |
$265.80
|
|
|
Spirometry before & after - RT CHARGE PFT
|
Facility
|
IP
|
$443.00
|
|
|
Service Code
|
HCPCS 94060
|
| Hospital Charge Code |
3900512
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$398.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$398.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$420.85
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Spirometry - RT CHARGE PFT
|
Facility
|
OP
|
$665.00
|
|
|
Service Code
|
HCPCS 94010
|
| Hospital Charge Code |
3900504
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$50.60 |
| Max. Negotiated Rate |
$631.75 |
| Rate for Payer: Aetna Commercial |
$598.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$300.98
|
| Rate for Payer: Humana Medicare Advantage |
$279.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$631.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.60
|
| Rate for Payer: WPPA Medicare Advantage |
$399.00
|
|
|
Spirometry - RT CHARGE PFT
|
Facility
|
IP
|
$665.00
|
|
|
Service Code
|
HCPCS 94010
|
| Hospital Charge Code |
3900504
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$598.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$598.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$631.75
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
spironolactone 25 mg Tab [HMC]
|
Facility
|
OP
|
$6.38
|
|
|
Service Code
|
NDC 68382066001
|
| Hospital Charge Code |
3807282
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$6.06 |
| Rate for Payer: Aetna Commercial |
$5.74
|
| Rate for Payer: Humana Medicare Advantage |
$2.68
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.55
|
| Rate for Payer: WPPA Medicare Advantage |
$3.83
|
|
|
spironolactone 25 mg Tab [HMC]
|
Facility
|
IP
|
$6.28
|
|
|
Service Code
|
NDC 63739054410
|
| Hospital Charge Code |
3807282
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.65
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.97
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
spironolactone 25 mg Tab [HMC]
|
Facility
|
OP
|
$6.28
|
|
|
Service Code
|
NDC 63739054410
|
| Hospital Charge Code |
3807282
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$5.97 |
| Rate for Payer: Aetna Commercial |
$5.65
|
| Rate for Payer: Humana Medicare Advantage |
$2.64
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.51
|
| Rate for Payer: WPPA Medicare Advantage |
$3.77
|
|
|
spironolactone 25 mg Tab [HMC]
|
Facility
|
IP
|
$5.56
|
|
|
Service Code
|
NDC 00904692761
|
| Hospital Charge Code |
3807282
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.28
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
spironolactone 25 mg Tab [HMC]
|
Facility
|
IP
|
$6.38
|
|
|
Service Code
|
NDC 68382066001
|
| Hospital Charge Code |
3807282
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.74 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.06
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
spironolactone 25 mg Tab [HMC]
|
Facility
|
OP
|
$6.28
|
|
|
Service Code
|
NDC 51079010320
|
| Hospital Charge Code |
3807282
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$5.97 |
| Rate for Payer: Aetna Commercial |
$5.65
|
| Rate for Payer: Humana Medicare Advantage |
$2.64
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.51
|
| Rate for Payer: WPPA Medicare Advantage |
$3.77
|
|
|
spironolactone 25 mg Tab [HMC]
|
Facility
|
OP
|
$5.56
|
|
|
Service Code
|
NDC 00904692761
|
| Hospital Charge Code |
3807282
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$5.28 |
| Rate for Payer: Aetna Commercial |
$5.00
|
| Rate for Payer: Humana Medicare Advantage |
$2.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.22
|
| Rate for Payer: WPPA Medicare Advantage |
$3.34
|
|
|
spironolactone 25 mg Tab [HMC]
|
Facility
|
IP
|
$6.28
|
|
|
Service Code
|
NDC 51079010320
|
| Hospital Charge Code |
3807282
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.65
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.97
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SPLENIC PROCEDURES WITH CC
|
Facility
|
IP
|
$9,848.70
|
|
|
Service Code
|
MSDRG 800
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$9,848.70 |
| Rate for Payer: UnitedHealthcare Medicaid |
$9,848.70
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SPLENIC PROCEDURES WITH MCC
|
Facility
|
IP
|
$15,885.00
|
|
|
Service Code
|
MSDRG 799
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$15,885.00 |
| Rate for Payer: UnitedHealthcare Medicaid |
$15,885.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
SPLENIC PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$6,703.47
|
|
|
Service Code
|
MSDRG 801
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$6,703.47 |
| Rate for Payer: UnitedHealthcare Medicaid |
$6,703.47
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Splint Cock-up Large Left
|
Facility
|
IP
|
$36.81
|
|
|
Service Code
|
HCPCS L3984
|
| Hospital Charge Code |
3251985
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$33.13 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$33.13
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.97
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
