|
norepinephrine 1 mg/mL solution 4 mL Vial
|
Facility
|
OP
|
$69.84
|
|
|
Service Code
|
NDC 67457085200
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$39.81 |
| Max. Negotiated Rate |
$69.84 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$49.24
|
| Rate for Payer: Aetna Workers' Compensation |
$49.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$48.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$48.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$55.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$55.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$55.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$53.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$55.03
|
| Rate for Payer: Cash Price |
$69.84
|
| Rate for Payer: Cigna Commercial |
$42.74
|
| Rate for Payer: Cigna Medicare Advantage |
$39.81
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$44.00
|
| Rate for Payer: Home State Health Plan Exchange |
$39.81
|
| Rate for Payer: Humana Medicare |
$52.38
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$52.38
|
| Rate for Payer: Provider Network of America Commercial |
$55.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$46.09
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$69.84
|
|
|
norepinephrine in dextrose 5 % 16 mcg/mL solution 250 mL Bag
|
Facility
|
IP
|
$90.48
|
|
|
Service Code
|
NDC 00338011220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.86 |
| 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 |
$90.48
|
| Rate for Payer: Cash Price |
$90.48
|
| 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 |
$67.86
|
| Rate for Payer: Provider Network of America Commercial |
$72.38
|
|
|
norepinephrine in dextrose 5 % 16 mcg/mL solution 250 mL Bag
|
Facility
|
OP
|
$90.48
|
|
|
Service Code
|
NDC 00338011220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.57 |
| Max. Negotiated Rate |
$90.48 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$63.79
|
| Rate for Payer: Aetna Workers' Compensation |
$63.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$62.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$62.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$71.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$71.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$71.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$69.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$71.30
|
| Rate for Payer: Cash Price |
$90.48
|
| Rate for Payer: Cigna Commercial |
$55.37
|
| Rate for Payer: Cigna Medicare Advantage |
$51.57
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$57.00
|
| Rate for Payer: Home State Health Plan Exchange |
$51.57
|
| Rate for Payer: Humana Medicare |
$67.86
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$67.86
|
| Rate for Payer: Provider Network of America Commercial |
$72.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$59.72
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$90.48
|
|
|
NORMAL NEWBORN
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 795
|
| 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 Freedom Network |
$1,293.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,293.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,293.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,293.00
|
| 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 |
$939.06
|
|
|
Normal saline solution infus
|
Facility
|
IP
|
$157.50
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
Px0636J705001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$118.12 |
| 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 |
$157.50
|
| Rate for Payer: Cash Price |
$157.50
|
| 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 |
$118.12
|
| Rate for Payer: Provider Network of America Commercial |
$126.00
|
|
|
Normal saline solution infus
|
Facility
|
OP
|
$157.50
|
|
|
Service Code
|
HCPCS J7050
|
| Hospital Charge Code |
Px0636J705001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.78 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$111.04
|
| Rate for Payer: Aetna Workers' Compensation |
$111.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$109.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$109.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$124.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$124.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$124.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$121.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$124.11
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$96.39
|
| Rate for Payer: Cigna Medicare Advantage |
$89.78
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$99.22
|
| Rate for Payer: Home State Health Plan Exchange |
$89.78
|
| Rate for Payer: Humana Medicare |
$118.12
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$118.12
|
| Rate for Payer: Provider Network of America Commercial |
$126.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$103.95
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$157.50
|
|
|
nortriptyline 10 mg capsule 100 Each Bottle
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00093081001
|
|
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
|
|
|
nortriptyline 10 mg capsule 100 Each Bottle
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00093081001
|
|
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
|
|
|
nortriptyline 10 mg capsule 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50268060311
|
|
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
|
|
|
nortriptyline 10 mg capsule 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50268060311
|
|
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
|
|
|
nortriptyline 25 mg capsule 100 Each Bottle
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00093081101
|
|
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
|
|
|
nortriptyline 25 mg capsule 100 Each Bottle
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00093081101
|
|
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
|
|
|
nortriptyline 25 mg capsule 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50268060411
|
|
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
|
|
|
nortriptyline 25 mg capsule 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50268060411
|
|
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
|
|
|
nortriptyline 25 mg capsule 50 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50268060415
|
|
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
|
|
|
nortriptyline 25 mg capsule 50 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50268060415
|
|
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
|
|
|
nystatin 100,000 unit/gram cream 15 g Tube
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
NDC 45802005935
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.92 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$39.48
|
| Rate for Payer: Aetna Workers' Compensation |
$39.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$38.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$38.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$44.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$44.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$44.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$43.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$44.13
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cigna Commercial |
$34.27
|
| Rate for Payer: Cigna Medicare Advantage |
$31.92
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$35.28
|
| Rate for Payer: Home State Health Plan Exchange |
$31.92
|
| Rate for Payer: Humana Medicare |
$42.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$42.00
|
| Rate for Payer: Provider Network of America Commercial |
$44.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.96
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$56.00
|
|
|
nystatin 100,000 unit/gram cream 15 g Tube
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
NDC 45802005935
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.00 |
| 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 |
$56.00
|
| Rate for Payer: Cash Price |
$56.00
|
| 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 |
$42.00
|
| Rate for Payer: Provider Network of America Commercial |
$44.80
|
|
|
nystatin 100,000 unit/gram powder 15 g SQUEEZ BTL
|
Facility
|
OP
|
$77.60
|
|
|
Service Code
|
NDC 69315030615
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.23 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$54.71
|
| Rate for Payer: Aetna Workers' Compensation |
$54.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$53.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$53.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$61.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$61.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$61.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$59.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$61.15
|
| Rate for Payer: Cash Price |
$77.60
|
| Rate for Payer: Cigna Commercial |
$47.49
|
| Rate for Payer: Cigna Medicare Advantage |
$44.23
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$48.89
|
| Rate for Payer: Home State Health Plan Exchange |
$44.23
|
| Rate for Payer: Humana Medicare |
$58.20
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$58.20
|
| Rate for Payer: Provider Network of America Commercial |
$62.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$51.22
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$77.60
|
|
|
nystatin 100,000 unit/gram powder 15 g SQUEEZ BTL
|
Facility
|
IP
|
$77.60
|
|
|
Service Code
|
NDC 69315030615
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.20 |
| 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 |
$77.60
|
| Rate for Payer: Cash Price |
$77.60
|
| 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 |
$58.20
|
| Rate for Payer: Provider Network of America Commercial |
$62.08
|
|
|
nystatin 100,000 unit/gram powder 15 g SQUEEZ BTL
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00832046515
|
|
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
|
|
|
nystatin 100,000 unit/gram powder 15 g SQUEEZ BTL
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00832046515
|
|
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
|
|
|
nystatin 100,000 unit/mL suspension 5 mL Cup
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00904727641
|
|
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
|
|
|
nystatin 100,000 unit/mL suspension 5 mL Cup
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00904727641
|
|
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
|
|
|
nystatin-triamcinolone 100,000-0.1 unit/g-% cream 15 g Tube
|
Facility
|
OP
|
$83.80
|
|
|
Service Code
|
NDC 45802088014
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.77 |
| Max. Negotiated Rate |
$83.80 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$59.08
|
| Rate for Payer: Aetna Workers' Compensation |
$59.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$58.07
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$58.07
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$66.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$66.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$66.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$64.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$66.03
|
| Rate for Payer: Cash Price |
$83.80
|
| Rate for Payer: Cigna Commercial |
$51.29
|
| Rate for Payer: Cigna Medicare Advantage |
$47.77
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$52.79
|
| Rate for Payer: Home State Health Plan Exchange |
$47.77
|
| Rate for Payer: Humana Medicare |
$62.85
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$62.85
|
| Rate for Payer: Provider Network of America Commercial |
$67.04
|
| Rate for Payer: UnitedHealthcare Commercial |
$55.31
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$83.80
|
|
