|
TRACHEOSTOMY INNER CANNULA SIZE 6 NON-FENESTRATED USE WITH SHILEY 6DFEN 6DCT
|
Facility
|
IP
|
$21.00
|
|
| Hospital Charge Code |
3251645
|
|
Hospital Revenue Code
|
270
|
| 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
|
|
|
TRACHEOSTOMY STRAPS TUBE HOLDER
|
Facility
|
OP
|
$12.96
|
|
| Hospital Charge Code |
3251635
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$12.31 |
| Rate for Payer: Aetna Commercial |
$11.66
|
| Rate for Payer: Humana Medicare Advantage |
$5.44
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.18
|
| Rate for Payer: WPPA Medicare Advantage |
$7.78
|
|
|
TRACHEOSTOMY STRAPS TUBE HOLDER
|
Facility
|
IP
|
$12.96
|
|
| Hospital Charge Code |
3251635
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.66 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$11.66
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.31
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES
|
Facility
|
IP
|
$39,204.18
|
|
|
Service Code
|
MSDRG 004
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$39,204.18 |
| Rate for Payer: UnitedHealthcare Medicaid |
$39,204.18
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Trach Speaking Valve Low Resist 15mm
|
Facility
|
OP
|
$276.00
|
|
| Hospital Charge Code |
3251642
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$110.40 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna Commercial |
$248.40
|
| Rate for Payer: Humana Medicare Advantage |
$115.92
|
| Rate for Payer: UnitedHealthcare Commercial |
$262.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$110.40
|
| Rate for Payer: WPPA Medicare Advantage |
$165.60
|
|
|
Trach Speaking Valve Low Resist 15mm
|
Facility
|
IP
|
$276.00
|
|
| Hospital Charge Code |
3251642
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$248.40 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$248.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$262.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
IP
|
$7.39
|
|
|
Service Code
|
NDC 51079099120
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.65 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.02
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
IP
|
$7.51
|
|
|
Service Code
|
NDC 57664037708
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.13
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
OP
|
$7.51
|
|
|
Service Code
|
NDC 57664037708
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$7.13 |
| Rate for Payer: Aetna Commercial |
$6.76
|
| Rate for Payer: Humana Medicare Advantage |
$3.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: WPPA Medicare Advantage |
$4.51
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
IP
|
$5.53
|
|
|
Service Code
|
NDC 60687079501
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.98 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.25
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
IP
|
$5.52
|
|
|
Service Code
|
NDC 00904717961
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.24
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
IP
|
$5.52
|
|
|
Service Code
|
NDC 00904749661
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$4.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.24
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
OP
|
$7.46
|
|
|
Service Code
|
NDC 68084080801
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$7.09 |
| Rate for Payer: Aetna Commercial |
$6.71
|
| Rate for Payer: Humana Medicare Advantage |
$3.13
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.98
|
| Rate for Payer: WPPA Medicare Advantage |
$4.48
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
IP
|
$7.46
|
|
|
Service Code
|
NDC 68084080801
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.09
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
OP
|
$7.46
|
|
|
Service Code
|
NDC 62584055901
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$7.09 |
| Rate for Payer: Aetna Commercial |
$6.71
|
| Rate for Payer: Humana Medicare Advantage |
$3.13
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.98
|
| Rate for Payer: WPPA Medicare Advantage |
$4.48
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
OP
|
$5.52
|
|
|
Service Code
|
NDC 00904749661
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$5.24 |
| Rate for Payer: Aetna Commercial |
$4.97
|
| Rate for Payer: Humana Medicare Advantage |
$2.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.21
|
| Rate for Payer: WPPA Medicare Advantage |
$3.31
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
IP
|
$7.46
|
|
|
Service Code
|
NDC 62584055901
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.09
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
OP
|
$5.53
|
|
|
Service Code
|
NDC 60687079501
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$5.25 |
| Rate for Payer: Aetna Commercial |
$4.98
|
| Rate for Payer: Humana Medicare Advantage |
$2.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.21
|
| Rate for Payer: WPPA Medicare Advantage |
$3.32
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
OP
|
$5.52
|
|
|
Service Code
|
NDC 00904717961
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$5.24 |
| Rate for Payer: Aetna Commercial |
$4.97
|
| Rate for Payer: Humana Medicare Advantage |
$2.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.21
|
| Rate for Payer: WPPA Medicare Advantage |
$3.31
|
|
|
traMADol 50 mg Tab [HMC]
|
Facility
|
OP
|
$7.39
|
|
|
Service Code
|
NDC 51079099120
|
| Hospital Charge Code |
3800360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$7.02 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Humana Medicare Advantage |
$3.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$7.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.96
|
| Rate for Payer: WPPA Medicare Advantage |
$4.43
|
|
|
tranexamic acid 100 mg/mL IV Sol [HMC]
|
Facility
|
IP
|
$42.80
|
|
|
Service Code
|
NDC 81284061210
|
| Hospital Charge Code |
3800315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.52 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$38.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$40.66
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
tranexamic acid 100 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$42.80
|
|
|
Service Code
|
NDC 81284061210
|
| Hospital Charge Code |
3800315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.12 |
| Max. Negotiated Rate |
$40.66 |
| Rate for Payer: Aetna Commercial |
$38.52
|
| Rate for Payer: Humana Medicare Advantage |
$17.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$40.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.12
|
| Rate for Payer: WPPA Medicare Advantage |
$25.68
|
|
|
tranexamic acid 100 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$57.43
|
|
|
Service Code
|
NDC 61990061102
|
| Hospital Charge Code |
3800315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.97 |
| Max. Negotiated Rate |
$54.56 |
| Rate for Payer: Aetna Commercial |
$51.69
|
| Rate for Payer: Humana Medicare Advantage |
$24.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$54.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.97
|
| Rate for Payer: WPPA Medicare Advantage |
$34.46
|
|
|
tranexamic acid 100 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$41.60
|
|
|
Service Code
|
NDC 25021041510
|
| Hospital Charge Code |
3800315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.64 |
| Max. Negotiated Rate |
$39.52 |
| Rate for Payer: Aetna Commercial |
$37.44
|
| Rate for Payer: Humana Medicare Advantage |
$17.47
|
| Rate for Payer: UnitedHealthcare Commercial |
$39.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.64
|
| Rate for Payer: WPPA Medicare Advantage |
$24.96
|
|
|
tranexamic acid 100 mg/mL IV Sol [HMC]
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
NDC 55150018810
|
| Hospital Charge Code |
3800315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.00 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Aetna Commercial |
$99.00
|
| Rate for Payer: Humana Medicare Advantage |
$46.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$104.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.00
|
| Rate for Payer: WPPA Medicare Advantage |
$66.00
|
|
