|
V-PATCH SMALL
|
Facility
|
OP
|
$924.00
|
|
| Hospital Charge Code |
1219124
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$332.64 |
| Max. Negotiated Rate |
$659.74 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$547.01
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$659.74
|
| Rate for Payer: Cash Price |
$831.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$616.31
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$332.64
|
|
|
V-PATCH SMALL
|
Facility
|
IP
|
$924.00
|
|
| Hospital Charge Code |
1219124
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$831.60
|
|
|
WAFER, STOMA--REF#14604
|
Facility
|
IP
|
$12.00
|
|
| Hospital Charge Code |
2819410
|
|
Hospital Revenue Code
|
271
|
| Rate for Payer: Cash Price |
$10.80
|
|
|
WAFER, STOMA--REF#14604
|
Facility
|
OP
|
$12.00
|
|
| Hospital Charge Code |
2819410
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$4.32 |
| Max. Negotiated Rate |
$8.57 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$7.10
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$8.57
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.00
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$4.32
|
|
|
WARFARIN
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 80375
|
| Hospital Charge Code |
22802991
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$63.55 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$52.69
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$63.55
|
| Rate for Payer: Cash Price |
$80.10
|
| Rate for Payer: Cash Price |
$80.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$21.00
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$32.04
|
|
|
WARFARIN
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 80375
|
| Hospital Charge Code |
22802991
|
|
Hospital Revenue Code
|
301
|
| Rate for Payer: Cash Price |
$80.10
|
|
|
WARFARIN 2MG TAB EMP
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 93171301
|
| Hospital Charge Code |
2620468
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$14.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$12.43
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.99
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.56
|
|
|
WARFARIN 2MG TAB EMP
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 93171301
|
| Hospital Charge Code |
2620468
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.90
|
|
|
WARFARIN (COUMADIN) 1MG TAB
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 93171201
|
| Hospital Charge Code |
2684638
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$14.28 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$11.84
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.28
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.34
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.20
|
|
|
WARFARIN (COUMADIN) 1MG TAB
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 93171201
|
| Hospital Charge Code |
2684638
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.00
|
|
|
WARFARIN (COUMADIN) 1MG TAB EMP
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 93171201
|
| Hospital Charge Code |
2622334
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.00
|
|
|
WARFARIN (COUMADIN) 1MG TAB EMP
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 93171201
|
| Hospital Charge Code |
2622334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$14.28 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$11.84
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.28
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.34
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.20
|
|
|
WARFARIN (COUMADIN) 2.5MG TAB
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 832121389
|
| Hospital Charge Code |
2624834
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$14.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$12.43
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.99
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.56
|
|
|
WARFARIN (COUMADIN) 2.5MG TAB
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 56017601
|
| Hospital Charge Code |
2656554
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$9.00
|
|
|
WARFARIN (COUMADIN) 2.5MG TAB
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 56017601
|
| Hospital Charge Code |
2656554
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$7.14 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$5.92
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$7.14
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.67
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$3.60
|
|
|
WARFARIN (COUMADIN) 2.5MG TAB
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 832121389
|
| Hospital Charge Code |
2624834
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.90
|
|
|
WARFARIN (COUMADIN) 2MG TAB
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 6.2584E+10
|
| Hospital Charge Code |
2656556
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.90
|
|
|
WARFARIN (COUMADIN) 2MG TAB
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 6.2584E+10
|
| Hospital Charge Code |
2656556
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$14.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$12.43
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.99
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.56
|
|
|
WARFARIN (COUMADIN) 3MG TAB
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 93171501
|
| Hospital Charge Code |
2697234
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$14.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$12.43
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.99
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.56
|
|
|
WARFARIN (COUMADIN) 3MG TAB
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 93171501
|
| Hospital Charge Code |
2697234
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.90
|
|
|
WARFARIN (COUMADIN) 5MG TAB EMP
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 56017275
|
| Hospital Charge Code |
2620259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$14.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$12.43
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.99
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.56
|
|
|
WARFARIN (COUMADIN) 5MG TAB EMP
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 56017275
|
| Hospital Charge Code |
2620259
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.90
|
|
|
WARFARIN (COUMADIN) 6MG TAB EMP
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 56018970
|
| Hospital Charge Code |
2622974
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.00
|
|
|
WARFARIN (COUMADIN) 6MG TAB EMP
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 56018970
|
| Hospital Charge Code |
2622974
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$14.28 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$11.84
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.28
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.34
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.20
|
|
|
WARMING BLANKET
|
Facility
|
IP
|
$58.00
|
|
| Hospital Charge Code |
2024486
|
|
Hospital Revenue Code
|
370
|
| Rate for Payer: Cash Price |
$52.20
|
|
