|
terbutaline 1 mg/mL Inj Sol [HMC]
|
Facility
|
IP
|
$27.80
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
3800619
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.02 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$25.02
|
| Rate for Payer: Aetna Commercial |
$39.60
|
| Rate for Payer: Aetna Commercial |
$49.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$52.69
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.80
|
| 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
|
|
|
TESTES PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$7,307.10
|
|
|
Service Code
|
MSDRG 711
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$7,307.10 |
| Rate for Payer: UnitedHealthcare Medicaid |
$7,307.10
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
TESTES PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$3,844.17
|
|
|
Service Code
|
MSDRG 712
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$3,844.17 |
| Rate for Payer: UnitedHealthcare Medicaid |
$3,844.17
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Testosterone, Free (Dialysis), Tot (MS) and SHGB QST
|
Facility
|
OP
|
$328.00
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
3553025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.47 |
| Max. Negotiated Rate |
$311.60 |
| Rate for Payer: Aetna Commercial |
$295.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$108.65
|
| Rate for Payer: Humana Medicare Advantage |
$137.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$311.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.47
|
| Rate for Payer: WPPA Medicare Advantage |
$196.80
|
|
|
Testosterone, Free (Dialysis), Tot (MS) and SHGB QST
|
Facility
|
IP
|
$328.00
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
3553025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$295.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$295.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$311.60
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Testosterone, Free QST
|
Facility
|
OP
|
$328.00
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
3553025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.47 |
| Max. Negotiated Rate |
$311.60 |
| Rate for Payer: Aetna Commercial |
$295.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$108.65
|
| Rate for Payer: Humana Medicare Advantage |
$137.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$311.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.47
|
| Rate for Payer: WPPA Medicare Advantage |
$196.80
|
|
|
Testosterone, Free QST
|
Facility
|
IP
|
$328.00
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
3553025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$295.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$295.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$311.60
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Testosterone Level Total
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
3557115
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$305.10 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$305.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$322.05
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Testosterone Level Total
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
3557115
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$322.05 |
| Rate for Payer: Aetna Commercial |
$305.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$104.86
|
| Rate for Payer: Humana Medicare Advantage |
$142.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$322.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.81
|
| Rate for Payer: WPPA Medicare Advantage |
$203.40
|
|
|
Tetanus Antitoxoid QST
|
Facility
|
IP
|
$233.00
|
|
|
Service Code
|
HCPCS 86774
|
| Hospital Charge Code |
3551641
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$209.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$209.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$221.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Tetanus Antitoxoid QST
|
Facility
|
OP
|
$233.00
|
|
|
Service Code
|
HCPCS 86774
|
| Hospital Charge Code |
3551641
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.58 |
| Max. Negotiated Rate |
$221.35 |
| Rate for Payer: Aetna Commercial |
$209.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$71.02
|
| Rate for Payer: Humana Medicare Advantage |
$97.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$221.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.58
|
| Rate for Payer: WPPA Medicare Advantage |
$139.80
|
|
|
tetanus/diphtheria/pertussis, acel (Tdap) 5 units-2 units-15.5 mcg/0.5 mL IM Susp 0 mL [HMC]
|
Facility
|
IP
|
$110.19
|
|
|
Service Code
|
NDC 49281040020
|
| Hospital Charge Code |
3804631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.17 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$99.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$104.68
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tetanus/diphtheria/pertussis, acel (Tdap) 5 units-2 units-15.5 mcg/0.5 mL IM Susp 0 mL [HMC]
|
Facility
|
OP
|
$110.19
|
|
|
Service Code
|
NDC 49281040010
|
| Hospital Charge Code |
3804631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.08 |
| Max. Negotiated Rate |
$104.68 |
| Rate for Payer: Aetna Commercial |
$99.17
|
| Rate for Payer: Humana Medicare Advantage |
$46.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$104.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.08
|
| Rate for Payer: WPPA Medicare Advantage |
$66.11
|
|
|
tetanus/diphtheria/pertussis, acel (Tdap) 5 units-2 units-15.5 mcg/0.5 mL IM Susp 0 mL [HMC]
|
Facility
|
OP
|
$110.19
|
|
|
Service Code
|
NDC 49281040020
|
| Hospital Charge Code |
3804631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.08 |
| Max. Negotiated Rate |
$104.68 |
| Rate for Payer: Aetna Commercial |
$99.17
|
| Rate for Payer: Humana Medicare Advantage |
$46.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$104.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.08
|
| Rate for Payer: WPPA Medicare Advantage |
$66.11
|
|
|
tetanus/diphtheria/pertussis, acel (Tdap) 5 units-2 units-15.5 mcg/0.5 mL IM Susp 0 mL [HMC]
|
Facility
|
IP
|
$110.19
|
|
|
Service Code
|
NDC 49281040010
|
| Hospital Charge Code |
3804631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.17 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$99.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$104.68
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tetanus/diphtheria/pertussis, acel (Tdap) 5 units-2 units-15.5 mcg/0.5 mL IM Susp 0 mL [HMC]
|
Facility
|
IP
|
$105.22
|
|
|
Service Code
|
NDC 49281040015
|
| Hospital Charge Code |
3804631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.70 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$94.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$99.96
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tetanus/diphtheria/pertussis, acel (Tdap) 5 units-2 units-15.5 mcg/0.5 mL IM Susp 0 mL [HMC]
|
Facility
|
OP
|
$105.22
|
|
|
Service Code
|
NDC 49281040015
|
| Hospital Charge Code |
3804631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.09 |
| Max. Negotiated Rate |
$99.96 |
| Rate for Payer: Aetna Commercial |
$94.70
|
| Rate for Payer: Humana Medicare Advantage |
$44.19
|
| Rate for Payer: UnitedHealthcare Commercial |
$99.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.09
|
| Rate for Payer: WPPA Medicare Advantage |
$63.13
|
|
|
tetanus-diphth toxoids (Td) adult/adol 5 units-2 units/0.5 mL preservative-free [HMC]
|
Facility
|
OP
|
$91.08
|
|
|
Service Code
|
NDC 49281021510
|
| Hospital Charge Code |
3804132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.43 |
| Max. Negotiated Rate |
$86.53 |
| Rate for Payer: Aetna Commercial |
$81.97
|
| Rate for Payer: Humana Medicare Advantage |
$38.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$86.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.43
|
| Rate for Payer: WPPA Medicare Advantage |
$54.65
|
|
|
tetanus-diphth toxoids (Td) adult/adol 5 units-2 units/0.5 mL preservative-free [HMC]
|
Facility
|
IP
|
$91.08
|
|
|
Service Code
|
NDC 49281021510
|
| Hospital Charge Code |
3804132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.97 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$81.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$86.53
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tetanus-diphth toxoids (Td) adult/adol 5 units-2 units/0.5 mL preservative-free Sus UD [HMC]
|
Facility
|
IP
|
$87.80
|
|
|
Service Code
|
NDC 49281021515
|
| Hospital Charge Code |
3804132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.02 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$79.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$83.41
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tetanus-diphth toxoids (Td) adult/adol 5 units-2 units/0.5 mL preservative-free Sus UD [HMC]
|
Facility
|
OP
|
$87.80
|
|
|
Service Code
|
NDC 49281021515
|
| Hospital Charge Code |
3804132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.12 |
| Max. Negotiated Rate |
$83.41 |
| Rate for Payer: Aetna Commercial |
$79.02
|
| Rate for Payer: Humana Medicare Advantage |
$36.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$83.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.12
|
| Rate for Payer: WPPA Medicare Advantage |
$52.68
|
|
|
tetracaine Ophth 0.5% Sol 4 mL [HMC]
|
Facility
|
IP
|
$43.80
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
3808547
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.42 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$39.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.61
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tetracaine Ophth 0.5% Sol 4 mL [HMC]
|
Facility
|
OP
|
$43.80
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
3808547
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.52 |
| Max. Negotiated Rate |
$41.61 |
| Rate for Payer: Aetna Commercial |
$39.42
|
| Rate for Payer: Humana Medicare Advantage |
$18.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.52
|
| Rate for Payer: WPPA Medicare Advantage |
$26.28
|
|
|
tetracaine Ophth 0.5% Sol [HMC]
|
Facility
|
IP
|
$35.81
|
|
|
Service Code
|
NDC 24208092064
|
| Hospital Charge Code |
3808547
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.23 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$32.23
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.02
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tetracaine Ophth 0.5% Sol [HMC]
|
Facility
|
OP
|
$35.81
|
|
|
Service Code
|
NDC 24208092064
|
| Hospital Charge Code |
3808547
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$34.02 |
| Rate for Payer: Aetna Commercial |
$32.23
|
| Rate for Payer: Humana Medicare Advantage |
$15.04
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.32
|
| Rate for Payer: WPPA Medicare Advantage |
$21.49
|
|
