|
micafungin 100 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
NDC 63323072901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$144.00 |
| 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 |
$192.00
|
| Rate for Payer: Cash Price |
$192.00
|
| 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 |
$144.00
|
| Rate for Payer: Provider Network of America Commercial |
$153.60
|
|
|
micafungin 100 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
HCPCS J2248
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$109.44 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$135.36
|
| Rate for Payer: Aetna Workers' Compensation |
$135.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$133.06
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$133.06
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$151.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$151.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$151.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$147.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$151.30
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cigna Commercial |
$117.50
|
| Rate for Payer: Cigna Medicare Advantage |
$109.44
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$120.96
|
| Rate for Payer: Home State Health Plan Exchange |
$109.44
|
| Rate for Payer: Humana Medicare |
$144.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$144.00
|
| Rate for Payer: Provider Network of America Commercial |
$153.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$126.72
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$192.00
|
|
|
Micafungin sodium injection
|
Facility
|
IP
|
$99.68
|
|
|
Service Code
|
HCPCS J2248
|
| Hospital Charge Code |
Px0636J224801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.76 |
| 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 |
$99.68
|
| Rate for Payer: Cash Price |
$99.68
|
| 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 |
$74.76
|
| Rate for Payer: Provider Network of America Commercial |
$79.74
|
|
|
Micafungin sodium injection
|
Facility
|
OP
|
$99.68
|
|
|
Service Code
|
HCPCS J2248
|
| Hospital Charge Code |
Px0636J224801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.82 |
| Max. Negotiated Rate |
$99.68 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$70.27
|
| Rate for Payer: Aetna Workers' Compensation |
$70.27
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$69.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$69.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$78.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$78.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$78.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$76.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$78.55
|
| Rate for Payer: Cash Price |
$99.68
|
| Rate for Payer: Cigna Commercial |
$61.00
|
| Rate for Payer: Cigna Medicare Advantage |
$56.82
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$62.80
|
| Rate for Payer: Home State Health Plan Exchange |
$56.82
|
| Rate for Payer: Humana Medicare |
$74.76
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$74.76
|
| Rate for Payer: Provider Network of America Commercial |
$79.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$65.79
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$99.68
|
|
|
Microfoam Tape 4"
|
Facility
|
IP
|
$106.09
|
|
|
Service Code
|
CPT A4452
|
| Hospital Charge Code |
Px0270A445203
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$79.57 |
| 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 |
$106.09
|
| Rate for Payer: Cash Price |
$106.09
|
| 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 |
$79.57
|
| Rate for Payer: Provider Network of America Commercial |
$84.87
|
|
|
Microfoam Tape 4"
|
Facility
|
OP
|
$106.09
|
|
|
Service Code
|
CPT A4452
|
| Hospital Charge Code |
Px0270A445203
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$60.47 |
| Max. Negotiated Rate |
$106.09 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$74.79
|
| Rate for Payer: Aetna Workers' Compensation |
$74.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$73.52
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$73.52
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$83.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$83.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$83.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$81.69
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$83.60
|
| Rate for Payer: Cash Price |
$106.09
|
| Rate for Payer: Cigna Commercial |
$64.93
|
| Rate for Payer: Cigna Medicare Advantage |
$60.47
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$66.84
|
| Rate for Payer: Home State Health Plan Exchange |
$60.47
|
| Rate for Payer: Humana Medicare |
$79.57
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$79.57
|
| Rate for Payer: Provider Network of America Commercial |
$84.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$70.02
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$106.09
|
|
|
midazolam 1 mg/mL solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00641605701
|
|
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
|
|
|
midazolam 1 mg/mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00641605701
|
|
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
|
|
|
midazolam 1 mg/mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J2250
|
|
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
|
|
|
midazolam 1 mg/mL solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J2250
|
|
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
|
|
|
midazolam 2 mg/mL syrup 5 mL Cup
|
Facility
|
OP
|
$24.44
|
|
|
Service Code
|
NDC 68094076459
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.93 |
| Max. Negotiated Rate |
$24.44 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$17.23
|
| Rate for Payer: Aetna Workers' Compensation |
$17.23
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$16.94
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$16.94
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$19.26
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$19.26
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$19.26
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$18.82
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$19.26
|
| Rate for Payer: Cash Price |
$24.44
|
| Rate for Payer: Cigna Commercial |
$14.96
|
| Rate for Payer: Cigna Medicare Advantage |
$13.93
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$15.40
|
| Rate for Payer: Home State Health Plan Exchange |
$13.93
|
| Rate for Payer: Humana Medicare |
$18.33
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$18.33
|
| Rate for Payer: Provider Network of America Commercial |
$19.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.13
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$24.44
|
|
|
midazolam 2 mg/mL syrup 5 mL Cup
|
Facility
|
IP
|
$24.44
|
|
|
Service Code
|
NDC 68094076459
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.33 |
| 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 |
$24.44
|
| Rate for Payer: Cash Price |
$24.44
|
| 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 |
$18.33
|
| Rate for Payer: Provider Network of America Commercial |
$19.55
|
|
|
midazolam 5 mg/mL solution 10 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00641619010
|
|
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
|
|
|
midazolam 5 mg/mL solution 10 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00641619010
|
|
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
|
|
|
midazolam 5 mg/mL solution 10 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J2250
|
|
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
|
|
|
midazolam 5 mg/mL solution 10 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J2250
|
|
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
|
|
|
midazolam (PF) 1 mg/mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00409230516
|
|
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
|
|
|
midazolam (PF) 1 mg/mL solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00409230516
|
|
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
|
|
|
midazolam (PF) 1 mg/mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J2250
|
|
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
|
|
|
midazolam (PF) 1 mg/mL solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J2250
|
|
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
|
|
|
midazolam (PF) 1 mg/mL solution 5 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00409230555
|
|
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
|
|
|
midazolam (PF) 1 mg/mL solution 5 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J2250
|
|
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
|
|
|
midazolam (PF) 1 mg/mL solution 5 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00409230555
|
|
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
|
|
|
midazolam (PF) 1 mg/mL solution 5 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J2250
|
|
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
|
|
|
midodrine 5 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904681861
|
|
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
|
|
