|
pantoprazole 40 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 71288060010
|
|
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
|
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
|
|
|
pantoprazole 40 mg tablet,delayed release (DR/EC) 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687073611
|
|
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
|
|
|
pantoprazole 40 mg tablet,delayed release (DR/EC) 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687073611
|
|
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
|
|
|
pantoprazole 40 mg tablet,delayed release (DR/EC) 50 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687073665
|
|
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
|
|
|
pantoprazole 40 mg tablet,delayed release (DR/EC) 50 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687073665
|
|
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
|
|
|
pantoprazole 40 mg tablet,delayed release (DR/EC) 80 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904687045
|
|
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
|
|
|
pantoprazole 40 mg tablet,delayed release (DR/EC) 80 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904687045
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Workers' Compensation |
$2.82
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$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
|
|
|
Parathyroid Planar Imaging
|
Facility
|
OP
|
$141.96
|
|
|
Service Code
|
CPT 78070
|
| Hospital Charge Code |
Px09727807001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$80.92 |
| Max. Negotiated Rate |
$544.89 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$100.08
|
| Rate for Payer: Aetna Workers' Compensation |
$100.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$98.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$98.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$111.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$111.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$111.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$109.31
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$111.86
|
| Rate for Payer: Cash Price |
$141.96
|
| Rate for Payer: Cash Price |
$141.96
|
| Rate for Payer: Cigna Commercial |
$86.88
|
| Rate for Payer: Cigna Medicare Advantage |
$80.92
|
| Rate for Payer: Family Health Partners Medicaid |
$504.53
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$89.43
|
| Rate for Payer: Healthy Blue Medicaid |
$544.89
|
| Rate for Payer: Home State Health Plan Exchange |
$80.92
|
| Rate for Payer: Home State Health Plan Medicaid |
$504.53
|
| Rate for Payer: Humana Medicare |
$106.47
|
| Rate for Payer: Mercy CarePlus Medicaid |
$504.53
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$106.47
|
| Rate for Payer: Provider Network of America Commercial |
$113.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$93.69
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$141.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$379.84
|
|
|
Parathyroid Planar Imaging
|
Facility
|
IP
|
$141.96
|
|
|
Service Code
|
CPT 78070
|
| Hospital Charge Code |
Px09727807001
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$106.47 |
| 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 |
$141.96
|
| Rate for Payer: Cash Price |
$141.96
|
| 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 |
$106.47
|
| Rate for Payer: Provider Network of America Commercial |
$113.57
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$9,189.72
|
|
|
Service Code
|
APR-DRG 8442
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$9,189.72 |
| 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 |
$9,189.72
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$9,189.72
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$9,189.72
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$9,189.72
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$16,285.40
|
|
|
Service Code
|
APR-DRG 8443
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$16,285.40 |
| 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 |
$16,285.40
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$16,285.40
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$16,285.40
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$16,285.40
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
APR-DRG 8441
|
| 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: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$5,315.98
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$5,315.98
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$5,315.98
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$5,315.98
|
|
|
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$31,036.10
|
|
|
Service Code
|
APR-DRG 8444
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$31,036.10 |
| 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: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$31,036.10
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$31,036.10
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$31,036.10
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$31,036.10
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 543
|
| 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: 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 |
$4,831.60
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC
|
Facility
|
IP
|
$8,302.55
|
|
|
Service Code
|
MSDRG 542
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$8,302.55 |
| 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 |
$8,302.55
|
|
|
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 544
|
| 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: 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 |
$3,546.62
|
|
|
pegfilgrastim 6 mg/0.6 mL syringe 0.6 mL Syringe
|
Facility
|
IP
|
$25,671.96
|
|
|
Service Code
|
NDC 55513019001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$20,537.57 |
| 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 |
$25,671.96
|
| Rate for Payer: Cash Price |
$25,671.96
|
| 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 |
$19,253.97
|
| Rate for Payer: Provider Network of America Commercial |
$20,537.57
|
|
|
pegfilgrastim 6 mg/0.6 mL syringe 0.6 mL Syringe
|
Facility
|
IP
|
$25,671.96
|
|
|
Service Code
|
HCPCS J2506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$20,537.57 |
| 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 |
$25,671.96
|
| Rate for Payer: Cash Price |
$25,671.96
|
| 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 |
$19,253.97
|
| Rate for Payer: Provider Network of America Commercial |
$20,537.57
|
|
|
pegfilgrastim 6 mg/0.6 mL syringe 0.6 mL Syringe
|
Facility
|
OP
|
$25,671.96
|
|
|
Service Code
|
HCPCS J2506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14,633.02 |
| Max. Negotiated Rate |
$25,671.96 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$18,098.73
|
| Rate for Payer: Aetna Workers' Compensation |
$18,098.73
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$17,790.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$17,790.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$20,229.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$20,229.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$20,229.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$19,767.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$20,229.50
|
| Rate for Payer: Cash Price |
$25,671.96
|
| Rate for Payer: Cigna Commercial |
$15,711.24
|
| Rate for Payer: Cigna Medicare Advantage |
$14,633.02
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$16,173.33
|
| Rate for Payer: Home State Health Plan Exchange |
$14,633.02
|
| Rate for Payer: Humana Medicare |
$19,253.97
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$19,253.97
|
| Rate for Payer: Provider Network of America Commercial |
$20,537.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$16,943.49
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$25,671.96
|
|
|
pegfilgrastim 6 mg/0.6 mL syringe 0.6 mL Syringe
|
Facility
|
OP
|
$25,671.96
|
|
|
Service Code
|
NDC 55513019001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14,633.02 |
| Max. Negotiated Rate |
$25,671.96 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$18,098.73
|
| Rate for Payer: Aetna Workers' Compensation |
$18,098.73
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$17,790.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$17,790.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$20,229.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$20,229.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$20,229.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$19,767.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$20,229.50
|
| Rate for Payer: Cash Price |
$25,671.96
|
| Rate for Payer: Cigna Commercial |
$15,711.24
|
| Rate for Payer: Cigna Medicare Advantage |
$14,633.02
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$16,173.33
|
| Rate for Payer: Home State Health Plan Exchange |
$14,633.02
|
| Rate for Payer: Humana Medicare |
$19,253.97
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$19,253.97
|
| Rate for Payer: Provider Network of America Commercial |
$20,537.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$16,943.49
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$25,671.96
|
|
|
pegfilgrastim-jmdb 6 mg/0.6 mL syringe 0.6 mL Syringe
|
Facility
|
IP
|
$8,350.00
|
|
|
Service Code
|
HCPCS Q5108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,680.00 |
| 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 |
$8,350.00
|
| Rate for Payer: Cash Price |
$8,350.00
|
| 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 |
$6,262.50
|
| Rate for Payer: Provider Network of America Commercial |
$6,680.00
|
|
|
pegfilgrastim-jmdb 6 mg/0.6 mL syringe 0.6 mL Syringe
|
Facility
|
OP
|
$8,350.00
|
|
|
Service Code
|
NDC 83257000541
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,759.50 |
| Max. Negotiated Rate |
$8,350.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5,886.75
|
| Rate for Payer: Aetna Workers' Compensation |
$5,886.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5,786.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5,786.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$6,579.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$6,579.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$6,579.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$6,429.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$6,579.80
|
| Rate for Payer: Cash Price |
$8,350.00
|
| Rate for Payer: Cigna Commercial |
$5,110.20
|
| Rate for Payer: Cigna Medicare Advantage |
$4,759.50
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$5,260.50
|
| Rate for Payer: Home State Health Plan Exchange |
$4,759.50
|
| Rate for Payer: Humana Medicare |
$6,262.50
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$6,262.50
|
| Rate for Payer: Provider Network of America Commercial |
$6,680.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,511.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$8,350.00
|
|
|
pegfilgrastim-jmdb 6 mg/0.6 mL syringe 0.6 mL Syringe
|
Facility
|
IP
|
$8,350.00
|
|
|
Service Code
|
NDC 83257000541
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,680.00 |
| 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 |
$8,350.00
|
| Rate for Payer: Cash Price |
$8,350.00
|
| 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 |
$6,262.50
|
| Rate for Payer: Provider Network of America Commercial |
$6,680.00
|
|
|
pegfilgrastim-jmdb 6 mg/0.6 mL syringe 0.6 mL Syringe
|
Facility
|
OP
|
$8,350.00
|
|
|
Service Code
|
HCPCS Q5108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,759.50 |
| Max. Negotiated Rate |
$8,350.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5,886.75
|
| Rate for Payer: Aetna Workers' Compensation |
$5,886.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5,786.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5,786.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$6,579.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$6,579.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$6,579.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$6,429.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$6,579.80
|
| Rate for Payer: Cash Price |
$8,350.00
|
| Rate for Payer: Cigna Commercial |
$5,110.20
|
| Rate for Payer: Cigna Medicare Advantage |
$4,759.50
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$5,260.50
|
| Rate for Payer: Home State Health Plan Exchange |
$4,759.50
|
| Rate for Payer: Humana Medicare |
$6,262.50
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$6,262.50
|
| Rate for Payer: Provider Network of America Commercial |
$6,680.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,511.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$8,350.00
|
|
