|
Azithromycin
|
Facility
|
OP
|
$26.25
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
Px0636J045601
|
|
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
|
|
|
azithromycin 200 mg/5 mL suspension for reconstitution 15 mL Bottle
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
NDC 42806014932
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.64 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$36.66
|
| Rate for Payer: Aetna Workers' Compensation |
$36.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$36.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$36.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$40.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$40.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$40.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$40.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$40.98
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cigna Commercial |
$31.82
|
| Rate for Payer: Cigna Medicare Advantage |
$29.64
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$32.76
|
| Rate for Payer: Home State Health Plan Exchange |
$29.64
|
| Rate for Payer: Humana Medicare |
$39.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$39.00
|
| Rate for Payer: Provider Network of America Commercial |
$41.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.32
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$52.00
|
|
|
azithromycin 200 mg/5 mL suspension for reconstitution 15 mL Bottle
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
NDC 42806014932
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.00 |
| 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 |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| 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 |
$39.00
|
| Rate for Payer: Provider Network of America Commercial |
$41.60
|
|
|
azithromycin 250 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$8.38
|
|
|
Service Code
|
NDC 00904735061
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.78 |
| Max. Negotiated Rate |
$8.38 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5.91
|
| Rate for Payer: Aetna Workers' Compensation |
$5.91
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$6.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$6.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$6.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$6.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$6.60
|
| Rate for Payer: Cash Price |
$8.38
|
| Rate for Payer: Cigna Commercial |
$5.13
|
| Rate for Payer: Cigna Medicare Advantage |
$4.78
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$5.28
|
| Rate for Payer: Home State Health Plan Exchange |
$4.78
|
| Rate for Payer: Humana Medicare |
$6.29
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$6.29
|
| Rate for Payer: Provider Network of America Commercial |
$6.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.53
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$8.38
|
|
|
azithromycin 250 mg tablet 100 Each BLIST PACK
|
Facility
|
IP
|
$8.38
|
|
|
Service Code
|
NDC 00904735061
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.29 |
| 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 |
$8.38
|
| Rate for Payer: Cash Price |
$8.38
|
| 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 |
$6.29
|
| Rate for Payer: Provider Network of America Commercial |
$6.70
|
|
|
azithromycin 500 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 25021018066
|
|
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
|
|
|
azithromycin 500 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J0456
|
|
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
|
|
|
azithromycin 500 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 70095002501
|
|
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
|
|
|
azithromycin 500 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J0456
|
|
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
|
|
|
azithromycin 500 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 70436001982
|
|
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
|
|
|
azithromycin 500 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 70095002501
|
|
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
|
|
|
azithromycin 500 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 25021018066
|
|
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
|
|
|
azithromycin 500 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 70436001982
|
|
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
|
|
|
bacitracin 500 unit/gram ointment 28.4 g Tube
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 10939056433
|
|
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
|
|
|
bacitracin 500 unit/gram ointment 28.4 g Tube
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00713028031
|
|
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
|
|
|
bacitracin 500 unit/gram ointment 28.4 g Tube
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 10939056433
|
|
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
|
|
|
bacitracin 500 unit/gram ointment 28.4 g Tube
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00713028031
|
|
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
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC
|
Facility
|
IP
|
$9,400.94
|
|
|
Service Code
|
MSDRG 519
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$9,400.94 |
| 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: 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 |
$9,400.94
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR
|
Facility
|
IP
|
$17,565.31
|
|
|
Service Code
|
MSDRG 518
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$17,565.31 |
| 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: 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 |
$17,565.31
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC
|
Facility
|
IP
|
$7,021.33
|
|
|
Service Code
|
MSDRG 520
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$7,021.33 |
| 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: 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 |
$7,021.33
|
|
|
baclofen 10 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687081501
|
|
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
|
|
|
baclofen 10 mg tablet 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687081501
|
|
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
|
|
|
baclofen 10 mg tablet 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687081511
|
|
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
|
|
|
baclofen 10 mg tablet 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687081511
|
|
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
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM
|
Facility
|
IP
|
$33,052.48
|
|
|
Service Code
|
APR-DRG 0494
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$33,052.48 |
| 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: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$33,052.48
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$33,052.48
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$33,052.48
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$33,052.48
|
|
