|
T3 Uptake QST
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS 84479
|
| Hospital Charge Code |
3552391
|
|
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
|
|
|
T3 Uptake QST
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
HCPCS 84479
|
| Hospital Charge Code |
3552391
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$19.95 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$18.84
|
| Rate for Payer: Humana Medicare Advantage |
$8.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.47
|
| Rate for Payer: WPPA Medicare Advantage |
$12.60
|
|
|
Tacrolimus, Highly Sens, LC/MS/MS QST
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
HCPCS 80197
|
| Hospital Charge Code |
3550846
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$172.90 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$67.35
|
| Rate for Payer: Humana Medicare Advantage |
$76.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$172.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.00
|
| Rate for Payer: WPPA Medicare Advantage |
$109.20
|
|
|
Tacrolimus, Highly Sens, LC/MS/MS QST
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS 80197
|
| Hospital Charge Code |
3550846
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$163.80 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$172.90
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tacrolimus Top 0.1% Oint [HMC]
|
Facility
|
IP
|
$371.61
|
|
|
Service Code
|
NDC 68462053435
|
| Hospital Charge Code |
3800818
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$334.45 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$334.45
|
| Rate for Payer: UnitedHealthcare Commercial |
$353.03
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tacrolimus Top 0.1% Oint [HMC]
|
Facility
|
OP
|
$371.61
|
|
|
Service Code
|
NDC 68462053435
|
| Hospital Charge Code |
3800818
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$148.64 |
| Max. Negotiated Rate |
$353.03 |
| Rate for Payer: Aetna Commercial |
$334.45
|
| Rate for Payer: Humana Medicare Advantage |
$156.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$353.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$148.64
|
| Rate for Payer: WPPA Medicare Advantage |
$222.97
|
|
|
tadalafil 20 mg Tab [HMC]
|
Facility
|
OP
|
$81.15
|
|
|
Service Code
|
NDC 68382089906
|
| Hospital Charge Code |
3859911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.46 |
| Max. Negotiated Rate |
$77.09 |
| Rate for Payer: Aetna Commercial |
$73.03
|
| Rate for Payer: Humana Medicare Advantage |
$34.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$77.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.46
|
| Rate for Payer: WPPA Medicare Advantage |
$48.69
|
|
|
tadalafil 20 mg Tab [HMC]
|
Facility
|
OP
|
$77.06
|
|
|
Service Code
|
NDC 29300028913
|
| Hospital Charge Code |
3859911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.82 |
| Max. Negotiated Rate |
$73.21 |
| Rate for Payer: Aetna Commercial |
$69.35
|
| Rate for Payer: Humana Medicare Advantage |
$32.37
|
| Rate for Payer: UnitedHealthcare Commercial |
$73.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.82
|
| Rate for Payer: WPPA Medicare Advantage |
$46.24
|
|
|
tadalafil 20 mg Tab [HMC]
|
Facility
|
IP
|
$77.06
|
|
|
Service Code
|
NDC 29300028913
|
| Hospital Charge Code |
3859911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.35 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$69.35
|
| Rate for Payer: UnitedHealthcare Commercial |
$73.21
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tadalafil 20 mg Tab [HMC]
|
Facility
|
IP
|
$81.15
|
|
|
Service Code
|
NDC 68382089906
|
| Hospital Charge Code |
3859911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.03 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$73.03
|
| Rate for Payer: UnitedHealthcare Commercial |
$77.09
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tamoxifen 10 mg Tab [HMC]
|
Facility
|
IP
|
$10.68
|
|
|
Service Code
|
NDC 00591247260
|
| Hospital Charge Code |
3806319
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$9.61
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.15
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tamoxifen 10 mg Tab [HMC]
|
Facility
|
OP
|
$6.72
|
|
|
Service Code
|
NDC 63739014310
|
| Hospital Charge Code |
3806319
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$6.38 |
| Rate for Payer: Aetna Commercial |
$6.05
|
| Rate for Payer: Humana Medicare Advantage |
$2.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.69
|
| Rate for Payer: WPPA Medicare Advantage |
$4.03
|
|
|
tamoxifen 10 mg Tab [HMC]
|
Facility
|
IP
|
$6.72
|
|
|
Service Code
|
NDC 63739014310
|
| Hospital Charge Code |
3806319
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.05 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.38
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tamoxifen 10 mg Tab [HMC]
|
Facility
|
OP
|
$10.68
|
|
|
Service Code
|
NDC 00591247260
|
| Hospital Charge Code |
3806319
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$10.15 |
| Rate for Payer: Aetna Commercial |
$9.61
|
| Rate for Payer: Humana Medicare Advantage |
$4.49
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.27
|
| Rate for Payer: WPPA Medicare Advantage |
$6.41
|
|
|
tamoxifen 20 mg Tab [HMC]
|
Facility
|
OP
|
$16.36
|
|
|
Service Code
|
NDC 00591247330
|
| Hospital Charge Code |
3800624
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.54 |
| Max. Negotiated Rate |
$15.54 |
| Rate for Payer: Aetna Commercial |
$14.72
|
| Rate for Payer: Humana Medicare Advantage |
$6.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$15.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.54
|
| Rate for Payer: WPPA Medicare Advantage |
$9.82
|
|
|
tamoxifen 20 mg Tab [HMC]
|
Facility
|
IP
|
$16.36
|
|
|
Service Code
|
NDC 00591247330
|
| Hospital Charge Code |
3800624
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$14.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$15.54
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tamoxifen 20 mg Tab [HMC]
|
Facility
|
OP
|
$16.36
|
|
|
Service Code
|
NDC 00378027493
|
| Hospital Charge Code |
3800624
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.54 |
| Max. Negotiated Rate |
$15.54 |
| Rate for Payer: Aetna Commercial |
$14.72
|
| Rate for Payer: Humana Medicare Advantage |
$6.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$15.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.54
|
| Rate for Payer: WPPA Medicare Advantage |
$9.82
|
|
|
tamoxifen 20 mg Tab [HMC]
|
Facility
|
IP
|
$16.36
|
|
|
Service Code
|
NDC 00378027493
|
| Hospital Charge Code |
3800624
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$14.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$15.54
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tamsulosin 0.4 mg Oral Cap [HMC]
|
Facility
|
OP
|
$17.64
|
|
|
Service Code
|
NDC 68084029901
|
| Hospital Charge Code |
3801772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$16.76 |
| Rate for Payer: Aetna Commercial |
$15.88
|
| Rate for Payer: Humana Medicare Advantage |
$7.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.06
|
| Rate for Payer: WPPA Medicare Advantage |
$10.58
|
|
|
tamsulosin 0.4 mg Oral Cap [HMC]
|
Facility
|
OP
|
$17.65
|
|
|
Service Code
|
NDC 65862059801
|
| Hospital Charge Code |
3801772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$16.77 |
| Rate for Payer: Aetna Commercial |
$15.88
|
| Rate for Payer: Humana Medicare Advantage |
$7.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.06
|
| Rate for Payer: WPPA Medicare Advantage |
$10.59
|
|
|
tamsulosin 0.4 mg Oral Cap [HMC]
|
Facility
|
OP
|
$6.60
|
|
|
Service Code
|
NDC 00904738361
|
| Hospital Charge Code |
3801772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$6.27 |
| Rate for Payer: Aetna Commercial |
$5.94
|
| Rate for Payer: Humana Medicare Advantage |
$2.77
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.64
|
| Rate for Payer: WPPA Medicare Advantage |
$3.96
|
|
|
tamsulosin 0.4 mg Oral Cap [HMC]
|
Facility
|
OP
|
$17.63
|
|
|
Service Code
|
NDC 00904640161
|
| Hospital Charge Code |
3801772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.05 |
| Max. Negotiated Rate |
$16.75 |
| Rate for Payer: Aetna Commercial |
$15.87
|
| Rate for Payer: Humana Medicare Advantage |
$7.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.05
|
| Rate for Payer: WPPA Medicare Advantage |
$10.58
|
|
|
tamsulosin 0.4 mg Oral Cap [HMC]
|
Facility
|
IP
|
$17.63
|
|
|
Service Code
|
NDC 00904640161
|
| Hospital Charge Code |
3801772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.87 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$15.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.75
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tamsulosin 0.4 mg Oral Cap [HMC]
|
Facility
|
IP
|
$17.64
|
|
|
Service Code
|
NDC 68084029901
|
| Hospital Charge Code |
3801772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.88 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$15.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.76
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tamsulosin 0.4 mg Oral Cap [HMC]
|
Facility
|
IP
|
$17.65
|
|
|
Service Code
|
NDC 65862059801
|
| Hospital Charge Code |
3801772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.88 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$15.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.77
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
