|
OLANZapine 10 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$201.04
|
|
|
Service Code
|
HCPCS J2359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$114.59 |
| Max. Negotiated Rate |
$201.04 |
| Rate for Payer: Aetna Workers' Compensation |
$56.40
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$141.73
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$56.40
|
| Rate for Payer: Aetna Workers' Compensation |
$141.73
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$139.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$55.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$139.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$55.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$63.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$158.42
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$63.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$158.42
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$158.42
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$63.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$154.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$61.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$63.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$158.42
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$201.04
|
| Rate for Payer: Cigna Commercial |
$123.04
|
| Rate for Payer: Cigna Commercial |
$48.96
|
| Rate for Payer: Cigna Medicare Advantage |
$114.59
|
| Rate for Payer: Cigna Medicare Advantage |
$45.60
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$126.66
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$50.40
|
| Rate for Payer: Home State Health Plan Exchange |
$114.59
|
| Rate for Payer: Home State Health Plan Exchange |
$45.60
|
| Rate for Payer: Humana Medicare |
$150.78
|
| Rate for Payer: Humana Medicare |
$60.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$150.78
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$60.00
|
| Rate for Payer: Provider Network of America Commercial |
$160.83
|
| Rate for Payer: Provider Network of America Commercial |
$64.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$132.69
|
| Rate for Payer: UnitedHealthcare Commercial |
$52.80
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$201.04
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$80.00
|
|
|
OLANZapine 5 mg tablet 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904637761
|
|
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
|
|
|
OLANZapine 5 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904637761
|
|
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
|
|
|
omalizumab 150 mg/mL syringe 1 mL Syringe
|
Facility
|
IP
|
$6,215.04
|
|
|
Service Code
|
HCPCS J2357
|
|
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 |
$6,215.04
|
| Rate for Payer: Cash Price |
$6,215.04
|
| 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 |
$4,661.28
|
| Rate for Payer: Provider Network of America Commercial |
$4,972.03
|
|
|
omalizumab 150 mg/mL syringe 1 mL Syringe
|
Facility
|
OP
|
$6,215.04
|
|
|
Service Code
|
HCPCS J2357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,542.57 |
| Max. Negotiated Rate |
$6,215.04 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$4,381.60
|
| Rate for Payer: Aetna Workers' Compensation |
$4,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$4,307.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$4,307.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$4,897.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$4,897.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$4,897.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$4,785.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$4,897.45
|
| Rate for Payer: Cash Price |
$6,215.04
|
| Rate for Payer: Cigna Commercial |
$3,803.60
|
| Rate for Payer: Cigna Medicare Advantage |
$3,542.57
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$3,915.48
|
| Rate for Payer: Home State Health Plan Exchange |
$3,542.57
|
| Rate for Payer: Humana Medicare |
$4,661.28
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$4,661.28
|
| Rate for Payer: Provider Network of America Commercial |
$4,972.03
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,101.93
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$6,215.04
|
|
|
omalizumab 150 mg/mL syringe 1 mL Syringe
|
Facility
|
IP
|
$6,215.04
|
|
|
Service Code
|
NDC 50242021501
|
|
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 |
$6,215.04
|
| Rate for Payer: Cash Price |
$6,215.04
|
| 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 |
$4,661.28
|
| Rate for Payer: Provider Network of America Commercial |
$4,972.03
|
|
|
omalizumab 150 mg/mL syringe 1 mL Syringe
|
Facility
|
OP
|
$6,215.04
|
|
|
Service Code
|
NDC 50242021501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,542.57 |
| Max. Negotiated Rate |
$6,215.04 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$4,381.60
|
| Rate for Payer: Aetna Workers' Compensation |
$4,381.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$4,307.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$4,307.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$4,897.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$4,897.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$4,897.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$4,785.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$4,897.45
|
| Rate for Payer: Cash Price |
$6,215.04
|
| Rate for Payer: Cigna Commercial |
$3,803.60
|
| Rate for Payer: Cigna Medicare Advantage |
$3,542.57
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$3,915.48
|
| Rate for Payer: Home State Health Plan Exchange |
$3,542.57
|
| Rate for Payer: Humana Medicare |
$4,661.28
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$4,661.28
|
| Rate for Payer: Provider Network of America Commercial |
$4,972.03
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,101.93
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$6,215.04
|
|
|
Omalizumab injection
|
Facility
|
IP
|
$4,346.50
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
Px0636J235701
|
|
Hospital Revenue Code
|
636
|
| 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 |
$4,346.50
|
| Rate for Payer: Cash Price |
$4,346.50
|
| 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 |
$3,259.88
|
| Rate for Payer: Provider Network of America Commercial |
$3,477.20
|
|
|
Omalizumab injection
|
Facility
|
OP
|
$4,346.50
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
Px0636J235701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,477.51 |
| Max. Negotiated Rate |
$4,346.50 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$3,064.28
|
| Rate for Payer: Aetna Workers' Compensation |
$3,064.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$3,012.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$3,012.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$3,425.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3,425.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$3,425.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3,346.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$3,425.04
|
| Rate for Payer: Cash Price |
$4,346.50
|
| Rate for Payer: Cigna Commercial |
$2,660.06
|
| Rate for Payer: Cigna Medicare Advantage |
$2,477.51
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2,738.30
|
| Rate for Payer: Home State Health Plan Exchange |
$2,477.51
|
| Rate for Payer: Humana Medicare |
$3,259.88
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3,259.88
|
| Rate for Payer: Provider Network of America Commercial |
$3,477.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,868.69
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$4,346.50
|
|
|
omega 3-dha-epa-fish oil 1,000 (120-180) mg capsule 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 77333030825
|
|
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
|
|
|
omega 3-dha-epa-fish oil 1,000 (120-180) mg capsule 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 77333030825
|
|
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
|
|
|
Ondansetron 4 mg
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS S0119
|
| Hospital Charge Code |
Px0636S011901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$3.52
|
| Rate for Payer: Aetna Workers' Compensation |
$3.52
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$3.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$3.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$3.94
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3.94
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$3.94
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$3.94
|
| Rate for Payer: Cash Price |
$5.00
|
| Rate for Payer: Cigna Commercial |
$3.06
|
| Rate for Payer: Cigna Medicare Advantage |
$2.85
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$3.15
|
| Rate for Payer: Home State Health Plan Exchange |
$2.85
|
| Rate for Payer: Humana Medicare |
$3.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Provider Network of America Commercial |
$4.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$3.30
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$5.00
|
|
|
Ondansetron 4 mg
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS S0119
|
| Hospital Charge Code |
Px0636S011901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.75 |
| 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 |
$5.00
|
| Rate for Payer: Cash Price |
$5.00
|
| 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 |
$3.75
|
| Rate for Payer: Provider Network of America Commercial |
$4.00
|
|
|
Ondansetron 4 mg
|
Professional
|
Both
|
$5.00
|
|
|
Service Code
|
HCPCS S0119
|
| Hospital Charge Code |
Px000000S0119
|
|
Hospital Revenue Code
|
520
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Cash Price |
$5.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1.75
|
|
|
ondansetron 4 mg/2 mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J2405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| 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: Provider Network of America Commercial |
$28.00
|
|
|
ondansetron 4 mg/2 mL solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J2405
|
|
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
|
|
|
ondansetron 4 mg/2 mL solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00641607801
|
|
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
|
|
|
ondansetron 4 mg/2 mL solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00641607825
|
|
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
|
|
|
ondansetron 4 mg/2 mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00641607801
|
|
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
|
|
|
ondansetron 4 mg/2 mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00641607825
|
|
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
|
|
|
Ondansetron Hcl 8mg Oral
|
Facility
|
OP
|
$53.82
|
|
|
Service Code
|
CPT Q0179
|
| Hospital Charge Code |
Px0636Q017901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.68 |
| Max. Negotiated Rate |
$53.82 |
| Rate for Payer: UnitedHealthcare Commercial |
$35.52
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$37.94
|
| Rate for Payer: Aetna Workers' Compensation |
$37.94
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$37.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$37.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$42.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$42.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$42.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$41.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$42.41
|
| Rate for Payer: Cash Price |
$53.82
|
| Rate for Payer: Cigna Commercial |
$32.94
|
| Rate for Payer: Cigna Medicare Advantage |
$30.68
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$33.91
|
| Rate for Payer: Home State Health Plan Exchange |
$30.68
|
| Rate for Payer: Humana Medicare |
$40.37
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$40.37
|
| Rate for Payer: Provider Network of America Commercial |
$43.06
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$53.82
|
|
|
Ondansetron Hcl 8mg Oral
|
Facility
|
IP
|
$53.82
|
|
|
Service Code
|
CPT Q0179
|
| Hospital Charge Code |
Px0636Q017901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.37 |
| 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 |
$53.82
|
| Rate for Payer: Cash Price |
$53.82
|
| 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 |
$40.37
|
| Rate for Payer: Provider Network of America Commercial |
$43.06
|
|
|
Ondansetron Hcl Injection
|
Facility
|
IP
|
$79.98
|
|
|
Service Code
|
CPT J2405
|
| Hospital Charge Code |
Px0636J240501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.98 |
| 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 |
$79.98
|
| Rate for Payer: Cash Price |
$79.98
|
| 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 |
$59.98
|
| Rate for Payer: Provider Network of America Commercial |
$63.98
|
|
|
Ondansetron Hcl Injection
|
Facility
|
OP
|
$79.98
|
|
|
Service Code
|
CPT J2405
|
| Hospital Charge Code |
Px0636J240501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.59 |
| Max. Negotiated Rate |
$79.98 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$56.39
|
| Rate for Payer: Aetna Workers' Compensation |
$56.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$55.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$55.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$63.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$63.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$63.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$61.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$63.02
|
| Rate for Payer: Cash Price |
$79.98
|
| Rate for Payer: Cigna Commercial |
$48.95
|
| Rate for Payer: Cigna Medicare Advantage |
$45.59
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$50.39
|
| Rate for Payer: Home State Health Plan Exchange |
$45.59
|
| Rate for Payer: Humana Medicare |
$59.98
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$59.98
|
| Rate for Payer: Provider Network of America Commercial |
$63.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$52.79
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$79.98
|
|
|
ondansetron ODT 4 mg tablet,disintegrating 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68462015740
|
|
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
|
|
