|
Dacarbazine 100 mg inj
|
Facility
|
IP
|
$163.23
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
Px0636J913001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.42 |
| 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 |
$163.23
|
| Rate for Payer: Cash Price |
$163.23
|
| 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 |
$122.42
|
| Rate for Payer: Provider Network of America Commercial |
$130.58
|
|
|
dalbavancin per 5 mg
|
Facility
|
OP
|
$7,116.00
|
|
|
Service Code
|
NDC 81298239001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,056.12 |
| Max. Negotiated Rate |
$7,116.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5,016.78
|
| Rate for Payer: Aetna Workers' Compensation |
$5,016.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$4,931.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$4,931.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$5,607.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$5,607.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$5,607.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$5,479.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$5,607.41
|
| Rate for Payer: Cash Price |
$7,116.00
|
| Rate for Payer: Cigna Commercial |
$4,354.99
|
| Rate for Payer: Cigna Medicare Advantage |
$4,056.12
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$4,483.08
|
| Rate for Payer: Home State Health Plan Exchange |
$4,056.12
|
| Rate for Payer: Humana Medicare |
$5,337.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5,337.00
|
| Rate for Payer: Provider Network of America Commercial |
$5,692.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,696.56
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7,116.00
|
|
|
dalbavancin per 5 mg
|
Facility
|
IP
|
$7,116.00
|
|
|
Service Code
|
NDC 81298239001
|
|
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 |
$7,116.00
|
| Rate for Payer: Cash Price |
$7,116.00
|
| 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 |
$5,337.00
|
| Rate for Payer: Provider Network of America Commercial |
$5,692.80
|
|
|
dalbavancin per 5 mg
|
Facility
|
IP
|
$7,116.00
|
|
|
Service Code
|
HCPCS J0875
|
|
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 |
$7,116.00
|
| Rate for Payer: Cash Price |
$7,116.00
|
| 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 |
$5,337.00
|
| Rate for Payer: Provider Network of America Commercial |
$5,692.80
|
|
|
dalbavancin per 5 mg
|
Facility
|
OP
|
$7,116.00
|
|
|
Service Code
|
HCPCS J0875
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,056.12 |
| Max. Negotiated Rate |
$7,116.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5,016.78
|
| Rate for Payer: Aetna Workers' Compensation |
$5,016.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$4,931.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$4,931.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$5,607.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$5,607.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$5,607.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$5,479.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$5,607.41
|
| Rate for Payer: Cash Price |
$7,116.00
|
| Rate for Payer: Cigna Commercial |
$4,354.99
|
| Rate for Payer: Cigna Medicare Advantage |
$4,056.12
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$4,483.08
|
| Rate for Payer: Home State Health Plan Exchange |
$4,056.12
|
| Rate for Payer: Humana Medicare |
$5,337.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5,337.00
|
| Rate for Payer: Provider Network of America Commercial |
$5,692.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,696.56
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7,116.00
|
|
|
dantrolene 20 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$280.00
|
|
|
Service Code
|
NDC 78670000367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$210.00 |
| 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 |
$280.00
|
| Rate for Payer: Cash Price |
$280.00
|
| 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 |
$210.00
|
| Rate for Payer: Provider Network of America Commercial |
$224.00
|
|
|
dantrolene 20 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$280.00
|
|
|
Service Code
|
NDC 78670000367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$159.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$197.40
|
| Rate for Payer: Aetna Workers' Compensation |
$197.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$194.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$194.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$220.64
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$220.64
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$220.64
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$215.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$220.64
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cigna Commercial |
$171.36
|
| Rate for Payer: Cigna Medicare Advantage |
$159.60
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$176.40
|
| Rate for Payer: Home State Health Plan Exchange |
$159.60
|
| Rate for Payer: Humana Medicare |
$210.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$210.00
|
| Rate for Payer: Provider Network of America Commercial |
$224.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$184.80
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$280.00
|
|
|
dantrolene 25 mg capsule 30 Each BLIST PACK
|
Facility
|
OP
|
$6.32
|
|
|
Service Code
|
NDC 00904721104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$6.32 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$4.46
|
| Rate for Payer: Aetna Workers' Compensation |
$4.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$4.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$4.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$4.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$4.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$4.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$4.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$4.98
|
| Rate for Payer: Cash Price |
$6.32
|
| Rate for Payer: Cigna Commercial |
$3.87
|
| Rate for Payer: Cigna Medicare Advantage |
$3.60
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$3.98
|
| Rate for Payer: Home State Health Plan Exchange |
$3.60
|
| Rate for Payer: Humana Medicare |
$4.74
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$4.74
|
| Rate for Payer: Provider Network of America Commercial |
$5.06
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.17
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$6.32
|
|
|
dantrolene 25 mg capsule 30 Each BLIST PACK
|
Facility
|
IP
|
$6.32
|
|
|
Service Code
|
NDC 00904721104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$6.32
|
| Rate for Payer: Cash Price |
$6.32
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$4.74
|
| Rate for Payer: Provider Network of America Commercial |
$5.06
|
|
|
Daptomycin injection
|
Facility
|
OP
|
$46.46
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
Px0636J087801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.48 |
| Max. Negotiated Rate |
$46.46 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$32.75
|
| Rate for Payer: Aetna Workers' Compensation |
$32.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$32.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$32.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$36.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$36.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$36.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$35.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$36.61
|
| Rate for Payer: Cash Price |
$46.46
|
| Rate for Payer: Cigna Commercial |
$28.43
|
| Rate for Payer: Cigna Medicare Advantage |
$26.48
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$29.27
|
| Rate for Payer: Home State Health Plan Exchange |
$26.48
|
| Rate for Payer: Humana Medicare |
$34.84
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$34.84
|
| Rate for Payer: Provider Network of America Commercial |
$37.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.66
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$46.46
|
|
|
Daptomycin injection
|
Facility
|
IP
|
$46.46
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
Px0636J087801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.84 |
| 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 |
$46.46
|
| Rate for Payer: Cash Price |
$46.46
|
| 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 |
$34.84
|
| Rate for Payer: Provider Network of America Commercial |
$37.17
|
|
|
daptomycin per 1 mg
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
NDC 60505622904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.40 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$84.60
|
| Rate for Payer: Aetna Workers' Compensation |
$84.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$92.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$94.56
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$73.44
|
| Rate for Payer: Cigna Medicare Advantage |
$68.40
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$75.60
|
| Rate for Payer: Home State Health Plan Exchange |
$68.40
|
| Rate for Payer: Humana Medicare |
$90.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$90.00
|
| Rate for Payer: Provider Network of America Commercial |
$96.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$79.20
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$120.00
|
|
|
daptomycin per 1 mg
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
NDC 71288001615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.40 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$84.60
|
| Rate for Payer: Aetna Workers' Compensation |
$84.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$92.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$94.56
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$73.44
|
| Rate for Payer: Cigna Medicare Advantage |
$68.40
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$75.60
|
| Rate for Payer: Home State Health Plan Exchange |
$68.40
|
| Rate for Payer: Humana Medicare |
$90.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$90.00
|
| Rate for Payer: Provider Network of America Commercial |
$96.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$79.20
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$120.00
|
|
|
daptomycin per 1 mg
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS J0878
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.40 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$84.60
|
| Rate for Payer: Aetna Workers' Compensation |
$84.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$92.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$94.56
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$73.44
|
| Rate for Payer: Cigna Medicare Advantage |
$68.40
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$75.60
|
| Rate for Payer: Home State Health Plan Exchange |
$68.40
|
| Rate for Payer: Humana Medicare |
$90.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$90.00
|
| Rate for Payer: Provider Network of America Commercial |
$96.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$79.20
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$120.00
|
|
|
daptomycin per 1 mg
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
NDC 60505622904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.00 |
| 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 |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| 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 |
$90.00
|
| Rate for Payer: Provider Network of America Commercial |
$96.00
|
|
|
daptomycin per 1 mg
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS J0878
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.00 |
| 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 |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| 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 |
$90.00
|
| Rate for Payer: Provider Network of America Commercial |
$96.00
|
|
|
daptomycin per 1 mg
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
NDC 71288001615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.00 |
| 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 |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| 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 |
$90.00
|
| Rate for Payer: Provider Network of America Commercial |
$96.00
|
|
|
darbepoetin alfa 100 mcg/mL solution 1 mL Vial
|
Facility
|
OP
|
$3,096.00
|
|
|
Service Code
|
NDC 55513000504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,764.72 |
| Max. Negotiated Rate |
$3,096.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2,182.68
|
| Rate for Payer: Aetna Workers' Compensation |
$2,182.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$2,145.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$2,145.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$2,439.65
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$2,439.65
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$2,439.65
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$2,383.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$2,439.65
|
| Rate for Payer: Cash Price |
$3,096.00
|
| Rate for Payer: Cigna Commercial |
$1,894.75
|
| Rate for Payer: Cigna Medicare Advantage |
$1,764.72
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,950.48
|
| Rate for Payer: Home State Health Plan Exchange |
$1,764.72
|
| Rate for Payer: Humana Medicare |
$2,322.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,322.00
|
| Rate for Payer: Provider Network of America Commercial |
$2,476.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,043.36
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$3,096.00
|
|
|
darbepoetin alfa 100 mcg/mL solution 1 mL Vial
|
Facility
|
OP
|
$3,096.00
|
|
|
Service Code
|
HCPCS J0882
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,764.72 |
| Max. Negotiated Rate |
$3,096.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2,182.68
|
| Rate for Payer: Aetna Workers' Compensation |
$2,182.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$2,145.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$2,145.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$2,439.65
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$2,439.65
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$2,439.65
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$2,383.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$2,439.65
|
| Rate for Payer: Cash Price |
$3,096.00
|
| Rate for Payer: Cigna Commercial |
$1,894.75
|
| Rate for Payer: Cigna Medicare Advantage |
$1,764.72
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,950.48
|
| Rate for Payer: Home State Health Plan Exchange |
$1,764.72
|
| Rate for Payer: Humana Medicare |
$2,322.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,322.00
|
| Rate for Payer: Provider Network of America Commercial |
$2,476.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,043.36
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$3,096.00
|
|
|
darbepoetin alfa 100 mcg/mL solution 1 mL Vial
|
Facility
|
IP
|
$3,096.00
|
|
|
Service Code
|
NDC 55513000504
|
|
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 |
$3,096.00
|
| Rate for Payer: Cash Price |
$3,096.00
|
| 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 |
$2,322.00
|
| Rate for Payer: Provider Network of America Commercial |
$2,476.80
|
|
|
darbepoetin alfa 100 mcg/mL solution 1 mL Vial
|
Facility
|
IP
|
$3,096.00
|
|
|
Service Code
|
HCPCS J0882
|
|
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 |
$3,096.00
|
| Rate for Payer: Cash Price |
$3,096.00
|
| 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 |
$2,322.00
|
| Rate for Payer: Provider Network of America Commercial |
$2,476.80
|
|
|
darbepoetin alfa in polysorbat 40 mcg/mL solution 1 mL Vial
|
Facility
|
OP
|
$1,238.40
|
|
|
Service Code
|
NDC 55513000304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$705.89 |
| Max. Negotiated Rate |
$1,238.40 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$873.07
|
| Rate for Payer: Aetna Workers' Compensation |
$873.07
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$858.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$858.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$975.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$975.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$975.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$953.57
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$975.86
|
| Rate for Payer: Cash Price |
$1,238.40
|
| Rate for Payer: Cigna Commercial |
$757.90
|
| Rate for Payer: Cigna Medicare Advantage |
$705.89
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$780.19
|
| Rate for Payer: Home State Health Plan Exchange |
$705.89
|
| Rate for Payer: Humana Medicare |
$928.80
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$928.80
|
| Rate for Payer: Provider Network of America Commercial |
$990.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$817.34
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,238.40
|
|
|
darbepoetin alfa in polysorbat 40 mcg/mL solution 1 mL Vial
|
Facility
|
IP
|
$1,238.40
|
|
|
Service Code
|
HCPCS J0882
|
|
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 |
$1,238.40
|
| Rate for Payer: Cash Price |
$1,238.40
|
| 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 |
$928.80
|
| Rate for Payer: Provider Network of America Commercial |
$990.72
|
|
|
darbepoetin alfa in polysorbat 40 mcg/mL solution 1 mL Vial
|
Facility
|
IP
|
$1,238.40
|
|
|
Service Code
|
NDC 55513000304
|
|
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 |
$1,238.40
|
| Rate for Payer: Cash Price |
$1,238.40
|
| 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 |
$928.80
|
| Rate for Payer: Provider Network of America Commercial |
$990.72
|
|
|
darbepoetin alfa in polysorbat 40 mcg/mL solution 1 mL Vial
|
Facility
|
OP
|
$1,238.40
|
|
|
Service Code
|
HCPCS J0882
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$705.89 |
| Max. Negotiated Rate |
$1,238.40 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$873.07
|
| Rate for Payer: Aetna Workers' Compensation |
$873.07
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$858.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$858.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$975.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$975.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$975.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$953.57
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$975.86
|
| Rate for Payer: Cash Price |
$1,238.40
|
| Rate for Payer: Cigna Commercial |
$757.90
|
| Rate for Payer: Cigna Medicare Advantage |
$705.89
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$780.19
|
| Rate for Payer: Home State Health Plan Exchange |
$705.89
|
| Rate for Payer: Humana Medicare |
$928.80
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$928.80
|
| Rate for Payer: Provider Network of America Commercial |
$990.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$817.34
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,238.40
|
|
