|
carbidopa-levodopa 25-250 mg tablet 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687083611
|
|
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
|
|
|
carbidopa-levodopa 25-250 mg tablet 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687083611
|
|
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
|
|
|
CARBOplatin 10 mg/mL solution 15 mL Vial
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS J9045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.88 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$59.22
|
| Rate for Payer: Aetna Workers' Compensation |
$59.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$58.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$58.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$66.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$66.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$66.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$64.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$66.19
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$51.41
|
| Rate for Payer: Cigna Medicare Advantage |
$47.88
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$52.92
|
| Rate for Payer: Home State Health Plan Exchange |
$47.88
|
| Rate for Payer: Humana Medicare |
$63.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Provider Network of America Commercial |
$67.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$55.44
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$84.00
|
|
|
CARBOplatin 10 mg/mL solution 15 mL Vial
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS J9045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.00 |
| 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 |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| 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 |
$63.00
|
| Rate for Payer: Provider Network of America Commercial |
$67.20
|
|
|
CARBOplatin 10 mg/mL solution 15 mL Vial
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
NDC 00703424601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.88 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$59.22
|
| Rate for Payer: Aetna Workers' Compensation |
$59.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$58.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$58.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$66.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$66.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$66.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$64.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$66.19
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$51.41
|
| Rate for Payer: Cigna Medicare Advantage |
$47.88
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$52.92
|
| Rate for Payer: Home State Health Plan Exchange |
$47.88
|
| Rate for Payer: Humana Medicare |
$63.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Provider Network of America Commercial |
$67.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$55.44
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$84.00
|
|
|
CARBOplatin 10 mg/mL solution 15 mL Vial
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
NDC 00703424601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.00 |
| 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 |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| 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 |
$63.00
|
| Rate for Payer: Provider Network of America Commercial |
$67.20
|
|
|
CARBOplatin 10 mg/mL solution 45 mL Vial
|
Facility
|
IP
|
$142.56
|
|
|
Service Code
|
HCPCS J9045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.92 |
| 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 |
$142.56
|
| Rate for Payer: Cash Price |
$142.56
|
| 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 |
$106.92
|
| Rate for Payer: Provider Network of America Commercial |
$114.05
|
|
|
CARBOplatin 10 mg/mL solution 45 mL Vial
|
Facility
|
OP
|
$142.56
|
|
|
Service Code
|
NDC 16729029534
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.26 |
| Max. Negotiated Rate |
$142.56 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$100.50
|
| Rate for Payer: Aetna Workers' Compensation |
$100.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$98.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$98.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$112.34
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$112.34
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$112.34
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$109.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$112.34
|
| Rate for Payer: Cash Price |
$142.56
|
| Rate for Payer: Cigna Commercial |
$87.25
|
| Rate for Payer: Cigna Medicare Advantage |
$81.26
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$89.81
|
| Rate for Payer: Home State Health Plan Exchange |
$81.26
|
| Rate for Payer: Humana Medicare |
$106.92
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$106.92
|
| Rate for Payer: Provider Network of America Commercial |
$114.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$94.09
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$142.56
|
|
|
CARBOplatin 10 mg/mL solution 45 mL Vial
|
Facility
|
OP
|
$142.56
|
|
|
Service Code
|
HCPCS J9045
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.26 |
| Max. Negotiated Rate |
$142.56 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$100.50
|
| Rate for Payer: Aetna Workers' Compensation |
$100.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$98.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$98.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$112.34
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$112.34
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$112.34
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$109.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$112.34
|
| Rate for Payer: Cash Price |
$142.56
|
| Rate for Payer: Cigna Commercial |
$87.25
|
| Rate for Payer: Cigna Medicare Advantage |
$81.26
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$89.81
|
| Rate for Payer: Home State Health Plan Exchange |
$81.26
|
| Rate for Payer: Humana Medicare |
$106.92
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$106.92
|
| Rate for Payer: Provider Network of America Commercial |
$114.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$94.09
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$142.56
|
|
|
CARBOplatin 10 mg/mL solution 45 mL Vial
|
Facility
|
IP
|
$142.56
|
|
|
Service Code
|
NDC 16729029534
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.92 |
| 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 |
$142.56
|
| Rate for Payer: Cash Price |
$142.56
|
| 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 |
$106.92
|
| Rate for Payer: Provider Network of America Commercial |
$114.05
|
|
|
Carboplatin injection
|
Facility
|
OP
|
$1,074.56
|
|
|
Service Code
|
HCPCS J9045
|
| Hospital Charge Code |
Px0636J904501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$612.50 |
| Max. Negotiated Rate |
$1,074.56 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$757.56
|
| Rate for Payer: Aetna Workers' Compensation |
$757.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$744.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$744.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$846.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$846.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$846.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$827.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$846.75
|
| Rate for Payer: Cash Price |
$1,074.56
|
| Rate for Payer: Cigna Commercial |
$657.63
|
| Rate for Payer: Cigna Medicare Advantage |
$612.50
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$676.97
|
| Rate for Payer: Home State Health Plan Exchange |
$612.50
|
| Rate for Payer: Humana Medicare |
$805.92
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$805.92
|
| Rate for Payer: Provider Network of America Commercial |
$859.65
|
| Rate for Payer: UnitedHealthcare Commercial |
$709.21
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,074.56
|
|
|
Carboplatin injection
|
Facility
|
IP
|
$1,074.56
|
|
|
Service Code
|
HCPCS J9045
|
| Hospital Charge Code |
Px0636J904501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$805.92 |
| 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 |
$1,074.56
|
| Rate for Payer: Cash Price |
$1,074.56
|
| 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 |
$805.92
|
| Rate for Payer: Provider Network of America Commercial |
$859.65
|
|
|
carboprost 250 mcg/mL solution 1 mL Vial
|
Facility
|
OP
|
$1,275.96
|
|
|
Service Code
|
NDC 43598069811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$727.30 |
| Max. Negotiated Rate |
$1,275.96 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$899.55
|
| Rate for Payer: Aetna Workers' Compensation |
$899.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$884.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$884.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,005.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,005.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,005.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$982.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,005.46
|
| Rate for Payer: Cash Price |
$1,275.96
|
| Rate for Payer: Cigna Commercial |
$780.89
|
| Rate for Payer: Cigna Medicare Advantage |
$727.30
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$803.85
|
| Rate for Payer: Home State Health Plan Exchange |
$727.30
|
| Rate for Payer: Humana Medicare |
$956.97
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$956.97
|
| Rate for Payer: Provider Network of America Commercial |
$1,020.77
|
| Rate for Payer: UnitedHealthcare Commercial |
$842.13
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,275.96
|
|
|
carboprost 250 mcg/mL solution 1 mL Vial
|
Facility
|
OP
|
$1,275.96
|
|
|
Service Code
|
HCPCS J0675
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$727.30 |
| Max. Negotiated Rate |
$1,275.96 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$899.55
|
| Rate for Payer: Aetna Workers' Compensation |
$899.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$884.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$884.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,005.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,005.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,005.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$982.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,005.46
|
| Rate for Payer: Cash Price |
$1,275.96
|
| Rate for Payer: Cigna Commercial |
$780.89
|
| Rate for Payer: Cigna Medicare Advantage |
$727.30
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$803.85
|
| Rate for Payer: Home State Health Plan Exchange |
$727.30
|
| Rate for Payer: Humana Medicare |
$956.97
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$956.97
|
| Rate for Payer: Provider Network of America Commercial |
$1,020.77
|
| Rate for Payer: UnitedHealthcare Commercial |
$842.13
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,275.96
|
|
|
carboprost 250 mcg/mL solution 1 mL Vial
|
Facility
|
IP
|
$1,275.96
|
|
|
Service Code
|
HCPCS J0675
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| 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 |
$1,275.96
|
| Rate for Payer: Cash Price |
$1,275.96
|
| 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 |
$956.97
|
| Rate for Payer: Provider Network of America Commercial |
$1,020.77
|
|
|
carboprost 250 mcg/mL solution 1 mL Vial
|
Facility
|
IP
|
$1,275.96
|
|
|
Service Code
|
NDC 43598069811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| 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 |
$1,275.96
|
| Rate for Payer: Cash Price |
$1,275.96
|
| 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 |
$956.97
|
| Rate for Payer: Provider Network of America Commercial |
$1,020.77
|
|
|
carboxymethylcellulose 0.5 % drops 15 mL DROP BTL
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00536138694
|
|
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
|
|
|
carboxymethylcellulose 0.5 % drops 15 mL DROP BTL
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 50268006815
|
|
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
|
|
|
carboxymethylcellulose 0.5 % drops 15 mL DROP BTL
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00536138694
|
|
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
|
|
|
carboxymethylcellulose 0.5 % drops 15 mL DROP BTL
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 50268006815
|
|
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
|
|
|
carboxymethylcellulose-glycern 0.5-0.9 % drops 15 mL DROP BTL
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00023324015
|
|
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
|
|
|
carboxymethylcellulose-glycern 0.5-0.9 % drops 15 mL DROP BTL
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00023324015
|
|
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
|
|
|
CARDIAC ARREST AND SHOCK
|
Facility
|
IP
|
$19,886.40
|
|
|
Service Code
|
APR-DRG 1964
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$19,886.40 |
| 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 |
$19,886.40
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$19,886.40
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$19,886.40
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$19,886.40
|
|
|
CARDIAC ARREST AND SHOCK
|
Facility
|
IP
|
$10,778.97
|
|
|
Service Code
|
APR-DRG 1963
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$10,778.97 |
| 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 |
$10,778.97
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$10,778.97
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$10,778.97
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$10,778.97
|
|
|
CARDIAC ARREST AND SHOCK
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
APR-DRG 1961
|
| Min. Negotiated Rate |
$875.00 |
| 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: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$4,967.44
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$4,967.44
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$4,967.44
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$4,967.44
|
|
