|
Strep Pneumoniae Ab IgG (14 Sero) QST
|
Facility
|
IP
|
$525.00
|
|
|
Service Code
|
HCPCS 86317
|
| Hospital Charge Code |
3552956
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$472.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$472.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$498.75
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Strep Pneumoniae Ab IgG (23 Sero) QST
|
Facility
|
OP
|
$856.00
|
|
|
Service Code
|
HCPCS 86317
|
| Hospital Charge Code |
3556317
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$813.20 |
| Rate for Payer: Aetna Commercial |
$770.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$44.56
|
| Rate for Payer: Humana Medicare Advantage |
$359.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$813.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.74
|
| Rate for Payer: WPPA Medicare Advantage |
$513.60
|
|
|
Strep Pneumoniae Ab IgG (23 Sero) QST
|
Facility
|
IP
|
$856.00
|
|
|
Service Code
|
HCPCS 86317
|
| Hospital Charge Code |
3556317
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$770.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$770.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$813.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
succinylcholine 20 mg/mL Inj Sol [HMC]
|
Facility
|
IP
|
$55.96
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
3800424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.36 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$50.36
|
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Commercial |
$49.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$52.13
|
| Rate for Payer: UnitedHealthcare Commercial |
$53.16
|
| 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
|
|
|
succinylcholine 20 mg/mL Inj Sol [HMC]
|
Facility
|
OP
|
$54.87
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
3800424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$52.13 |
| Rate for Payer: Aetna Commercial |
$49.38
|
| Rate for Payer: Aetna Commercial |
$50.36
|
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$1.02
|
| Rate for Payer: Humana Medicare Advantage |
$23.50
|
| Rate for Payer: Humana Medicare Advantage |
$15.96
|
| Rate for Payer: Humana Medicare Advantage |
$23.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$53.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$52.13
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.85
|
| Rate for Payer: WPPA Medicare Advantage |
$33.58
|
| Rate for Payer: WPPA Medicare Advantage |
$22.80
|
| Rate for Payer: WPPA Medicare Advantage |
$32.92
|
|
|
sucralfate 1 g/10 mL 420 mL Sus [HMC]
|
Facility
|
OP
|
$29.94
|
|
|
Service Code
|
NDC 65162006205
|
| Hospital Charge Code |
3809148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$28.44 |
| Rate for Payer: Aetna Commercial |
$26.95
|
| Rate for Payer: Humana Medicare Advantage |
$12.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.98
|
| Rate for Payer: WPPA Medicare Advantage |
$17.96
|
|
|
sucralfate 1 g/10 mL 420 mL Sus [HMC]
|
Facility
|
IP
|
$29.94
|
|
|
Service Code
|
NDC 65162006205
|
| Hospital Charge Code |
3809148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.95 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$26.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.44
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
sucralfate 1 g/10 mL Oral Susp [HMC]
|
Facility
|
IP
|
$25.05
|
|
|
Service Code
|
NDC 50268074514
|
| Hospital Charge Code |
3800972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.55 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$22.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
sucralfate 1 g/10 mL Oral Susp [HMC]
|
Facility
|
IP
|
$28.27
|
|
|
Service Code
|
NDC 50268073212
|
| Hospital Charge Code |
3800972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.44 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.86
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
sucralfate 1 g/10 mL Oral Susp [HMC]
|
Facility
|
OP
|
$25.05
|
|
|
Service Code
|
NDC 00904726918
|
| Hospital Charge Code |
3800972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.02 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: Aetna Commercial |
$22.55
|
| Rate for Payer: Humana Medicare Advantage |
$10.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.02
|
| Rate for Payer: WPPA Medicare Advantage |
$15.03
|
|
|
sucralfate 1 g/10 mL Oral Susp [HMC]
|
Facility
|
IP
|
$553.24
|
|
|
Service Code
|
NDC 00121074710
|
| Hospital Charge Code |
3800972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$497.92 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$497.92
|
| Rate for Payer: UnitedHealthcare Commercial |
$525.58
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
sucralfate 1 g/10 mL Oral Susp [HMC]
|
Facility
|
OP
|
$25.05
|
|
|
Service Code
|
NDC 50268074514
|
| Hospital Charge Code |
3800972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.02 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: Aetna Commercial |
$22.55
|
| Rate for Payer: Humana Medicare Advantage |
$10.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.02
|
| Rate for Payer: WPPA Medicare Advantage |
$15.03
|
|
|
sucralfate 1 g/10 mL Oral Susp [HMC]
|
Facility
|
IP
|
$26.37
|
|
|
Service Code
|
NDC 68094004362
|
| Hospital Charge Code |
3800972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.73 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$23.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$25.05
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
sucralfate 1 g/10 mL Oral Susp [HMC]
|
Facility
|
OP
|
$28.27
|
|
|
Service Code
|
NDC 50268073212
|
| Hospital Charge Code |
3800972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.31 |
| Max. Negotiated Rate |
$26.86 |
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: Humana Medicare Advantage |
$11.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.31
|
| Rate for Payer: WPPA Medicare Advantage |
$16.96
|
|
|
sucralfate 1 g/10 mL Oral Susp [HMC]
|
Facility
|
OP
|
$26.37
|
|
|
Service Code
|
NDC 68094004362
|
| Hospital Charge Code |
3800972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.55 |
| Max. Negotiated Rate |
$25.05 |
| Rate for Payer: Aetna Commercial |
$23.73
|
| Rate for Payer: Humana Medicare Advantage |
$11.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$25.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.55
|
| Rate for Payer: WPPA Medicare Advantage |
$15.82
|
|
|
sucralfate 1 g/10 mL Oral Susp [HMC]
|
Facility
|
IP
|
$25.05
|
|
|
Service Code
|
NDC 00904726918
|
| Hospital Charge Code |
3800972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.55 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$22.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.80
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
sucralfate 1 g/10 mL Oral Susp [HMC]
|
Facility
|
OP
|
$553.24
|
|
|
Service Code
|
NDC 00121074710
|
| Hospital Charge Code |
3800972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$221.30 |
| Max. Negotiated Rate |
$525.58 |
| Rate for Payer: Aetna Commercial |
$497.92
|
| Rate for Payer: Humana Medicare Advantage |
$232.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$525.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$221.30
|
| Rate for Payer: WPPA Medicare Advantage |
$331.94
|
|
|
sucralfate 1 g Tab [HMC]
|
Facility
|
IP
|
$6.14
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
3807316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.53
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.83
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
sucralfate 1 g Tab [HMC]
|
Facility
|
IP
|
$7.33
|
|
|
Service Code
|
NDC 00093221005
|
| Hospital Charge Code |
3807316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.96
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
sucralfate 1 g Tab [HMC]
|
Facility
|
IP
|
$6.38
|
|
|
Service Code
|
NDC 60687069501
|
| Hospital Charge Code |
3807316
|
|
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
|
|
|
sucralfate 1 g Tab [HMC]
|
Facility
|
OP
|
$6.38
|
|
|
Service Code
|
NDC 60687069501
|
| Hospital Charge Code |
3807316
|
|
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
|
|
|
sucralfate 1 g Tab [HMC]
|
Facility
|
OP
|
$6.14
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
3807316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$5.83 |
| Rate for Payer: Aetna Commercial |
$5.53
|
| Rate for Payer: Humana Medicare Advantage |
$2.58
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.46
|
| Rate for Payer: WPPA Medicare Advantage |
$3.68
|
|
|
sucralfate 1 g Tab [HMC]
|
Facility
|
IP
|
$7.41
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
3807316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.67 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.67
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.04
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
sucralfate 1 g Tab [HMC]
|
Facility
|
OP
|
$7.33
|
|
|
Service Code
|
NDC 00093221005
|
| Hospital Charge Code |
3807316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.93 |
| Max. Negotiated Rate |
$6.96 |
| Rate for Payer: Aetna Commercial |
$6.60
|
| Rate for Payer: Humana Medicare Advantage |
$3.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.93
|
| Rate for Payer: WPPA Medicare Advantage |
$4.40
|
|
|
sucralfate 1 g Tab [HMC]
|
Facility
|
OP
|
$7.41
|
|
|
Service Code
|
NDC 00093221001
|
| Hospital Charge Code |
3807316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$7.04 |
| Rate for Payer: Aetna Commercial |
$6.67
|
| Rate for Payer: Humana Medicare Advantage |
$3.11
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.96
|
| Rate for Payer: WPPA Medicare Advantage |
$4.45
|
|
