|
ammonia 15 % (w/v) solution 1 Each AMPUL
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS J7699
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2.82
|
| Rate for Payer: Aetna Workers' Compensation |
$2.82
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$2.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$2.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$3.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$3.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$3.15
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Cigna Commercial |
$2.45
|
| Rate for Payer: Cigna Medicare Advantage |
$2.28
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2.52
|
| Rate for Payer: Home State Health Plan Exchange |
$2.28
|
| Rate for Payer: Humana Medicare |
$3.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3.00
|
| Rate for Payer: Provider Network of America Commercial |
$3.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.64
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$4.00
|
|
|
ammonia 15 % (w/v) solution 1 Each AMPUL
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 39822990001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2.82
|
| Rate for Payer: Aetna Workers' Compensation |
$2.82
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$2.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$2.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$3.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$3.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$3.15
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Cigna Commercial |
$2.45
|
| Rate for Payer: Cigna Medicare Advantage |
$2.28
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2.52
|
| Rate for Payer: Home State Health Plan Exchange |
$2.28
|
| Rate for Payer: Humana Medicare |
$3.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3.00
|
| Rate for Payer: Provider Network of America Commercial |
$3.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.64
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$4.00
|
|
|
amoxicillin 400 mg/5 mL suspension for reconstitution 100 mL Bottle
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00093416173
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.75 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$33.75
|
| Rate for Payer: Provider Network of America Commercial |
$36.00
|
|
|
amoxicillin 400 mg/5 mL suspension for reconstitution 100 mL Bottle
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00093416173
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.65 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$31.73
|
| Rate for Payer: Aetna Workers' Compensation |
$31.73
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$31.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$31.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$35.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$35.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$35.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$34.65
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$35.46
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$27.54
|
| Rate for Payer: Cigna Medicare Advantage |
$25.65
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$28.35
|
| Rate for Payer: Home State Health Plan Exchange |
$25.65
|
| Rate for Payer: Humana Medicare |
$33.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$33.75
|
| Rate for Payer: Provider Network of America Commercial |
$36.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$29.70
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$45.00
|
|
|
amoxicillin 500 mg capsule 100 Each Bottle
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00781261301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2.82
|
| Rate for Payer: Aetna Workers' Compensation |
$2.82
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$2.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$2.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$3.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$3.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$3.15
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Cigna Commercial |
$2.45
|
| Rate for Payer: Cigna Medicare Advantage |
$2.28
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2.52
|
| Rate for Payer: Home State Health Plan Exchange |
$2.28
|
| Rate for Payer: Humana Medicare |
$3.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3.00
|
| Rate for Payer: Provider Network of America Commercial |
$3.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.64
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$4.00
|
|
|
amoxicillin 500 mg capsule 100 Each Bottle
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00781261301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3.00
|
| Rate for Payer: Provider Network of America Commercial |
$3.20
|
|
|
amoxicillin-pot clavulanate 500-125 mg tablet 20 Each Bottle
|
Facility
|
OP
|
$5.64
|
|
|
Service Code
|
NDC 00093227434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$5.64 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$3.98
|
| Rate for Payer: Aetna Workers' Compensation |
$3.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$3.91
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$3.91
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$4.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$4.34
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$4.44
|
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Cigna Commercial |
$3.45
|
| Rate for Payer: Cigna Medicare Advantage |
$3.21
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$3.55
|
| Rate for Payer: Home State Health Plan Exchange |
$3.21
|
| Rate for Payer: Humana Medicare |
$4.23
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$4.23
|
| Rate for Payer: Provider Network of America Commercial |
$4.51
|
| Rate for Payer: UnitedHealthcare Commercial |
$3.72
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$5.64
|
|
|
amoxicillin-pot clavulanate 500-125 mg tablet 20 Each Bottle
|
Facility
|
IP
|
$5.64
|
|
|
Service Code
|
NDC 00093227434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$4.23
|
| Rate for Payer: Provider Network of America Commercial |
$4.51
|
|
|
amoxicillin-pot clavulanate 875-125 mg tablet 20 Each Bottle
|
Facility
|
IP
|
$6.75
|
|
|
Service Code
|
NDC 00093227534
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5.06
|
| Rate for Payer: Provider Network of America Commercial |
$5.40
|
|
|
amoxicillin-pot clavulanate 875-125 mg tablet 20 Each Bottle
|
Facility
|
OP
|
$6.75
|
|
|
Service Code
|
NDC 00093227534
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$6.75 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$4.76
|
| Rate for Payer: Aetna Workers' Compensation |
$4.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$4.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$4.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$5.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$5.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$5.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$5.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$5.32
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cigna Commercial |
$4.13
|
| Rate for Payer: Cigna Medicare Advantage |
$3.85
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$4.25
|
| Rate for Payer: Home State Health Plan Exchange |
$3.85
|
| Rate for Payer: Humana Medicare |
$5.06
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5.06
|
| Rate for Payer: Provider Network of America Commercial |
$5.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.46
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$6.75
|
|
|
Amphotericin b
|
Facility
|
OP
|
$108.33
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
Px0636J028501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.75 |
| Max. Negotiated Rate |
$108.33 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$76.37
|
| Rate for Payer: Aetna Workers' Compensation |
$76.37
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$75.07
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$75.07
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$85.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$85.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$85.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$83.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$85.36
|
| Rate for Payer: Cash Price |
$108.33
|
| Rate for Payer: Cigna Commercial |
$66.30
|
| Rate for Payer: Cigna Medicare Advantage |
$61.75
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$68.25
|
| Rate for Payer: Home State Health Plan Exchange |
$61.75
|
| Rate for Payer: Humana Medicare |
$81.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$81.25
|
| Rate for Payer: Provider Network of America Commercial |
$86.66
|
| Rate for Payer: UnitedHealthcare Commercial |
$71.50
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$108.33
|
|
|
Amphotericin b
|
Facility
|
IP
|
$108.33
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
Px0636J028501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.25 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$108.33
|
| Rate for Payer: Cash Price |
$108.33
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$81.25
|
| Rate for Payer: Provider Network of America Commercial |
$86.66
|
|
|
Ampicillin 500 mg inj
|
Facility
|
OP
|
$54.24
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
Px0636J029001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.92 |
| Max. Negotiated Rate |
$54.24 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$38.24
|
| Rate for Payer: Aetna Workers' Compensation |
$38.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$37.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$37.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$42.74
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$42.74
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$42.74
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$41.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$42.74
|
| Rate for Payer: Cash Price |
$54.24
|
| Rate for Payer: Cigna Commercial |
$33.19
|
| Rate for Payer: Cigna Medicare Advantage |
$30.92
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$34.17
|
| Rate for Payer: Home State Health Plan Exchange |
$30.92
|
| Rate for Payer: Humana Medicare |
$40.68
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$40.68
|
| Rate for Payer: Provider Network of America Commercial |
$43.39
|
| Rate for Payer: UnitedHealthcare Commercial |
$35.80
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$54.24
|
|
|
Ampicillin 500 mg inj
|
Facility
|
IP
|
$54.24
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
Px0636J029001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.68 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$54.24
|
| Rate for Payer: Cash Price |
$54.24
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$40.68
|
| Rate for Payer: Provider Network of America Commercial |
$43.39
|
|
|
ampicillin per 500 mg
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$24.68
|
| Rate for Payer: Aetna Workers' Compensation |
$24.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$26.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$27.58
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Commercial |
$21.42
|
| Rate for Payer: Cigna Medicare Advantage |
$19.95
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$22.05
|
| Rate for Payer: Home State Health Plan Exchange |
$19.95
|
| Rate for Payer: Humana Medicare |
$26.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Provider Network of America Commercial |
$28.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.10
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$35.00
|
|
|
ampicillin per 500 mg
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 55150011310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$24.68
|
| Rate for Payer: Aetna Workers' Compensation |
$24.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$26.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$27.58
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Commercial |
$21.42
|
| Rate for Payer: Cigna Medicare Advantage |
$19.95
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$22.05
|
| Rate for Payer: Home State Health Plan Exchange |
$19.95
|
| Rate for Payer: Humana Medicare |
$26.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Provider Network of America Commercial |
$28.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.10
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$35.00
|
|
|
ampicillin per 500 mg
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Provider Network of America Commercial |
$28.00
|
|
|
ampicillin per 500 mg
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 55150011310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Provider Network of America Commercial |
$28.00
|
|
|
ampicillin sodium 10 gram recon soln 1 Each Bottle
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
NDC 70860011899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$225.00
|
| Rate for Payer: Provider Network of America Commercial |
$240.00
|
|
|
ampicillin sodium 10 gram recon soln 1 Each Bottle
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
NDC 70860011899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$211.50
|
| Rate for Payer: Aetna Workers' Compensation |
$211.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$207.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$207.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$236.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$236.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$236.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$231.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$236.40
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$183.60
|
| Rate for Payer: Cigna Medicare Advantage |
$171.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$189.00
|
| Rate for Payer: Home State Health Plan Exchange |
$171.00
|
| Rate for Payer: Humana Medicare |
$225.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$225.00
|
| Rate for Payer: Provider Network of America Commercial |
$240.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$198.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$300.00
|
|
|
Ampicillin sulbactam 1.5 gm
|
Facility
|
IP
|
$26.25
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
Px0636J029501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.69 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$26.25
|
| Rate for Payer: Cash Price |
$26.25
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$19.69
|
| Rate for Payer: Provider Network of America Commercial |
$21.00
|
|
|
Ampicillin sulbactam 1.5 gm
|
Facility
|
OP
|
$26.25
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
Px0636J029501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$18.51
|
| Rate for Payer: Aetna Workers' Compensation |
$18.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$18.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$18.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$20.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$20.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$20.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$20.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$20.68
|
| Rate for Payer: Cash Price |
$26.25
|
| Rate for Payer: Cigna Commercial |
$16.07
|
| Rate for Payer: Cigna Medicare Advantage |
$14.96
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$16.54
|
| Rate for Payer: Home State Health Plan Exchange |
$14.96
|
| Rate for Payer: Humana Medicare |
$19.69
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$19.69
|
| Rate for Payer: Provider Network of America Commercial |
$21.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.32
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$26.25
|
|
|
ampicillin-sulbactam 1.5 gram recon soln 1 Each Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 55150011620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Provider Network of America Commercial |
$28.00
|
|
|
ampicillin-sulbactam 1.5 gram recon soln 1 Each Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 55150011620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$24.68
|
| Rate for Payer: Aetna Workers' Compensation |
$24.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$26.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$27.58
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Commercial |
$21.42
|
| Rate for Payer: Cigna Medicare Advantage |
$19.95
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$22.05
|
| Rate for Payer: Home State Health Plan Exchange |
$19.95
|
| Rate for Payer: Humana Medicare |
$26.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Provider Network of America Commercial |
$28.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.10
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$35.00
|
|
|
ampicillin-sulbactam 1.5 gram recon soln 1 Each Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Provider Network of America Commercial |
$28.00
|
|
