|
PANCREAS TRANSPLANT
|
Facility
|
IP
|
$112,773.75
|
|
|
Service Code
|
APR-DRG 0064
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$112,773.75 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$112,773.75
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$112,773.75
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$112,773.75
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$112,773.75
|
|
|
PANCREAS TRANSPLANT
|
Facility
|
IP
|
$55,198.41
|
|
|
Service Code
|
APR-DRG 0061
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$55,198.41 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$55,198.41
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$55,198.41
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$55,198.41
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$55,198.41
|
|
|
PANCREAS TRANSPLANT
|
Facility
|
IP
|
$76,394.85
|
|
|
Service Code
|
APR-DRG 0062
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$76,394.85 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$76,394.85
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$76,394.85
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$76,394.85
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$76,394.85
|
|
|
PANCREAS TRANSPLANT
|
Facility
|
IP
|
$92,181.02
|
|
|
Service Code
|
APR-DRG 0063
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$92,181.02 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$92,181.02
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$92,181.02
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$92,181.02
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$92,181.02
|
|
|
PANCREAS TRANSPLANT
|
Facility
|
IP
|
$14,428.53
|
|
|
Service Code
|
MSDRG 010
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$14,428.53 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$14,428.53
|
|
|
panitumumab 400 mg/20 mL (20 mg/mL) solution 20 mL Vial
|
Facility
|
IP
|
$30,435.72
|
|
|
Service Code
|
HCPCS J9303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$24,348.58 |
| 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 |
$30,435.72
|
| Rate for Payer: Cash Price |
$30,435.72
|
| 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 |
$22,826.79
|
| Rate for Payer: Provider Network of America Commercial |
$24,348.58
|
|
|
panitumumab 400 mg/20 mL (20 mg/mL) solution 20 mL Vial
|
Facility
|
OP
|
$30,435.72
|
|
|
Service Code
|
HCPCS J9303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17,348.36 |
| Max. Negotiated Rate |
$30,435.72 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$21,457.18
|
| Rate for Payer: Aetna Workers' Compensation |
$21,457.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$21,091.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$21,091.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$23,983.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$23,983.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$23,983.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$23,435.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$23,983.35
|
| Rate for Payer: Cash Price |
$30,435.72
|
| Rate for Payer: Cigna Commercial |
$18,626.66
|
| Rate for Payer: Cigna Medicare Advantage |
$17,348.36
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$19,174.50
|
| Rate for Payer: Home State Health Plan Exchange |
$17,348.36
|
| Rate for Payer: Humana Medicare |
$22,826.79
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$22,826.79
|
| Rate for Payer: Provider Network of America Commercial |
$24,348.58
|
| Rate for Payer: UnitedHealthcare Commercial |
$20,087.58
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$30,435.72
|
|
|
panitumumab 400 mg/20 mL (20 mg/mL) solution 20 mL Vial
|
Facility
|
OP
|
$30,435.72
|
|
|
Service Code
|
NDC 55513095601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17,348.36 |
| Max. Negotiated Rate |
$30,435.72 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$21,457.18
|
| Rate for Payer: Aetna Workers' Compensation |
$21,457.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$21,091.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$21,091.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$23,983.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$23,983.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$23,983.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$23,435.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$23,983.35
|
| Rate for Payer: Cash Price |
$30,435.72
|
| Rate for Payer: Cigna Commercial |
$18,626.66
|
| Rate for Payer: Cigna Medicare Advantage |
$17,348.36
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$19,174.50
|
| Rate for Payer: Home State Health Plan Exchange |
$17,348.36
|
| Rate for Payer: Humana Medicare |
$22,826.79
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$22,826.79
|
| Rate for Payer: Provider Network of America Commercial |
$24,348.58
|
| Rate for Payer: UnitedHealthcare Commercial |
$20,087.58
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$30,435.72
|
|
|
panitumumab 400 mg/20 mL (20 mg/mL) solution 20 mL Vial
|
Facility
|
IP
|
$30,435.72
|
|
|
Service Code
|
NDC 55513095601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$24,348.58 |
| 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 |
$30,435.72
|
| Rate for Payer: Cash Price |
$30,435.72
|
| 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 |
$22,826.79
|
| Rate for Payer: Provider Network of America Commercial |
$24,348.58
|
|
|
Panitumumab injection
|
Facility
|
IP
|
$32,131.37
|
|
|
Service Code
|
HCPCS J9303
|
| Hospital Charge Code |
Px0636J930301
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$25,705.10 |
| 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 |
$32,131.37
|
| Rate for Payer: Cash Price |
$32,131.37
|
| 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 |
$24,098.53
|
| Rate for Payer: Provider Network of America Commercial |
$25,705.10
|
|
|
Panitumumab injection
|
Facility
|
OP
|
$32,131.37
|
|
|
Service Code
|
HCPCS J9303
|
| Hospital Charge Code |
Px0636J930301
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,314.88 |
| Max. Negotiated Rate |
$32,131.37 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$22,652.62
|
| Rate for Payer: Aetna Workers' Compensation |
$22,652.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$22,267.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$22,267.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$25,319.52
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$25,319.52
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$25,319.52
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$24,741.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$25,319.52
|
| Rate for Payer: Cash Price |
$32,131.37
|
| Rate for Payer: Cigna Commercial |
$19,664.40
|
| Rate for Payer: Cigna Medicare Advantage |
$18,314.88
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$20,242.76
|
| Rate for Payer: Home State Health Plan Exchange |
$18,314.88
|
| Rate for Payer: Humana Medicare |
$24,098.53
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$24,098.53
|
| Rate for Payer: Provider Network of America Commercial |
$25,705.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$21,206.70
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$32,131.37
|
|
|
panitumumab per 10 mg
|
Facility
|
OP
|
$7,608.92
|
|
|
Service Code
|
HCPCS J9303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,337.08 |
| Max. Negotiated Rate |
$7,608.92 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5,364.29
|
| Rate for Payer: Aetna Workers' Compensation |
$5,364.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5,272.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5,272.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$5,995.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$5,995.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$5,995.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$5,858.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$5,995.83
|
| Rate for Payer: Cash Price |
$7,608.92
|
| Rate for Payer: Cigna Commercial |
$4,656.66
|
| Rate for Payer: Cigna Medicare Advantage |
$4,337.08
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$4,793.62
|
| Rate for Payer: Home State Health Plan Exchange |
$4,337.08
|
| Rate for Payer: Humana Medicare |
$5,706.69
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5,706.69
|
| Rate for Payer: Provider Network of America Commercial |
$6,087.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,021.89
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7,608.92
|
|
|
panitumumab per 10 mg
|
Facility
|
IP
|
$7,608.92
|
|
|
Service Code
|
HCPCS J9303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,087.14 |
| 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 |
$7,608.92
|
| Rate for Payer: Cash Price |
$7,608.92
|
| 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 |
$5,706.69
|
| Rate for Payer: Provider Network of America Commercial |
$6,087.14
|
|
|
panitumumab per 10 mg
|
Facility
|
OP
|
$7,608.92
|
|
|
Service Code
|
NDC 55513095401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,337.08 |
| Max. Negotiated Rate |
$7,608.92 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5,364.29
|
| Rate for Payer: Aetna Workers' Compensation |
$5,364.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5,272.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5,272.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$5,995.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$5,995.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$5,995.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$5,858.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$5,995.83
|
| Rate for Payer: Cash Price |
$7,608.92
|
| Rate for Payer: Cigna Commercial |
$4,656.66
|
| Rate for Payer: Cigna Medicare Advantage |
$4,337.08
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$4,793.62
|
| Rate for Payer: Home State Health Plan Exchange |
$4,337.08
|
| Rate for Payer: Humana Medicare |
$5,706.69
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5,706.69
|
| Rate for Payer: Provider Network of America Commercial |
$6,087.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,021.89
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7,608.92
|
|
|
panitumumab per 10 mg
|
Facility
|
IP
|
$7,608.92
|
|
|
Service Code
|
NDC 55513095401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,087.14 |
| 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 |
$7,608.92
|
| Rate for Payer: Cash Price |
$7,608.92
|
| 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 |
$5,706.69
|
| Rate for Payer: Provider Network of America Commercial |
$6,087.14
|
|
|
pantoprazole 40 mg granules DR for susp in packet 1 Each Packet
|
Facility
|
OP
|
$56.63
|
|
|
Service Code
|
NDC 27241025611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.28 |
| Max. Negotiated Rate |
$56.63 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$39.92
|
| Rate for Payer: Aetna Workers' Compensation |
$39.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$39.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$39.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$44.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$43.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$44.62
|
| Rate for Payer: Cash Price |
$56.63
|
| Rate for Payer: Cigna Commercial |
$34.66
|
| Rate for Payer: Cigna Medicare Advantage |
$32.28
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$35.68
|
| Rate for Payer: Home State Health Plan Exchange |
$32.28
|
| Rate for Payer: Humana Medicare |
$42.47
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$42.47
|
| Rate for Payer: Provider Network of America Commercial |
$45.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.38
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$56.63
|
|
|
pantoprazole 40 mg granules DR for susp in packet 1 Each Packet
|
Facility
|
IP
|
$56.63
|
|
|
Service Code
|
NDC 27241025611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.47 |
| 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 |
$56.63
|
| Rate for Payer: Cash Price |
$56.63
|
| 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 |
$42.47
|
| Rate for Payer: Provider Network of America Commercial |
$45.30
|
|
|
pantoprazole 40 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J2471
|
|
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
|
|
|
pantoprazole 40 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00143928401
|
|
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
|
|
|
pantoprazole 40 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J2471
|
|
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
|
|
|
pantoprazole 40 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00143928401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Workers' Compensation |
$24.68
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$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
|
|
|
pantoprazole 40 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J2470
|
|
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
|
|
|
pantoprazole 40 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J2470
|
|
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
|
|
|
pantoprazole 40 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 71288060010
|
|
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
|
|
|
pantoprazole 40 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 71288060011
|
|
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
|
|
