|
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 998
|
| 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 |
$1,185.00
|
|
|
procainamide 100 mg/mL syringe 10 mL Syringe
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
NDC 76329339905
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$255.00 |
| 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 |
$340.00
|
| Rate for Payer: Cash Price |
$340.00
|
| 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 |
$255.00
|
| Rate for Payer: Provider Network of America Commercial |
$272.00
|
|
|
procainamide 100 mg/mL syringe 10 mL Syringe
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
NDC 76329339905
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$193.80 |
| Max. Negotiated Rate |
$340.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$239.70
|
| Rate for Payer: Aetna Workers' Compensation |
$239.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$235.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$235.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$267.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$267.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$267.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$261.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$267.92
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cigna Commercial |
$208.08
|
| Rate for Payer: Cigna Medicare Advantage |
$193.80
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$214.20
|
| Rate for Payer: Home State Health Plan Exchange |
$193.80
|
| Rate for Payer: Humana Medicare |
$255.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$255.00
|
| Rate for Payer: Provider Network of America Commercial |
$272.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$224.40
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$340.00
|
|
|
Procainamide hcl injection
|
Facility
|
IP
|
$149.48
|
|
|
Service Code
|
HCPCS J2690
|
| Hospital Charge Code |
Px0636J269001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.11 |
| 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 |
$149.48
|
| Rate for Payer: Cash Price |
$149.48
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$112.11
|
| Rate for Payer: Provider Network of America Commercial |
$119.58
|
|
|
Procainamide hcl injection
|
Facility
|
OP
|
$149.48
|
|
|
Service Code
|
HCPCS J2690
|
| Hospital Charge Code |
Px0636J269001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.20 |
| Max. Negotiated Rate |
$149.48 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$105.38
|
| Rate for Payer: Aetna Workers' Compensation |
$105.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$103.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$103.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$117.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$117.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$117.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$115.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$117.79
|
| Rate for Payer: Cash Price |
$149.48
|
| Rate for Payer: Cigna Commercial |
$91.48
|
| Rate for Payer: Cigna Medicare Advantage |
$85.20
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$94.17
|
| Rate for Payer: Home State Health Plan Exchange |
$85.20
|
| Rate for Payer: Humana Medicare |
$112.11
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$112.11
|
| Rate for Payer: Provider Network of America Commercial |
$119.58
|
| Rate for Payer: UnitedHealthcare Commercial |
$98.66
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$149.48
|
|
|
Pro Cath Cardiovascular Procedure Unlisted
|
Facility
|
IP
|
$277.20
|
|
|
Service Code
|
CPT 93799
|
| Hospital Charge Code |
Px09839379901
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$207.90 |
| 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 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 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: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cash Price |
$277.20
|
| Rate for Payer: Cash Price |
$277.20
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$207.90
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$198.00
|
| Rate for Payer: Provider Network of America Commercial |
$221.76
|
| Rate for Payer: Provider Network of America Commercial |
$211.20
|
|
|
Pro Cath Cardiovascular Procedure Unlisted
|
Facility
|
OP
|
$277.20
|
|
|
Service Code
|
CPT 93799
|
| Hospital Charge Code |
Px09839379901
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$122.26 |
| Max. Negotiated Rate |
$277.20 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$195.43
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$186.12
|
| Rate for Payer: Aetna Workers' Compensation |
$195.43
|
| Rate for Payer: Aetna Workers' Compensation |
$186.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$192.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$182.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$192.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$182.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$218.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$208.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$218.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$208.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$208.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$218.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$203.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$213.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$218.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$208.03
|
| Rate for Payer: Cash Price |
$277.20
|
| Rate for Payer: Cash Price |
$277.20
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cigna Commercial |
$169.65
|
| Rate for Payer: Cigna Commercial |
$161.57
|
| Rate for Payer: Cigna Medicare Advantage |
$150.48
|
| Rate for Payer: Cigna Medicare Advantage |
$158.00
|
| Rate for Payer: Family Health Partners Medicaid |
$162.40
|
| Rate for Payer: Family Health Partners Medicaid |
$162.40
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$174.64
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$166.32
|
| Rate for Payer: Healthy Blue Medicaid |
$175.39
|
| Rate for Payer: Healthy Blue Medicaid |
$175.39
|
| Rate for Payer: Home State Health Plan Exchange |
$158.00
|
| Rate for Payer: Home State Health Plan Exchange |
$150.48
|
| Rate for Payer: Home State Health Plan Medicaid |
$162.40
|
| Rate for Payer: Home State Health Plan Medicaid |
$162.40
|
| Rate for Payer: Humana Medicare |
$198.00
|
| Rate for Payer: Humana Medicare |
$207.90
|
| Rate for Payer: Mercy CarePlus Medicaid |
$162.40
|
| Rate for Payer: Mercy CarePlus Medicaid |
$162.40
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$198.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$207.90
|
| Rate for Payer: Provider Network of America Commercial |
$211.20
|
| Rate for Payer: Provider Network of America Commercial |
$221.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$174.24
|
| Rate for Payer: UnitedHealthcare Commercial |
$182.95
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$264.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$277.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$122.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$122.26
|
|
|
PROCEDURES FOR OBESITY
|
Facility
|
IP
|
$23,283.09
|
|
|
Service Code
|
APR-DRG 4033
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$23,283.09 |
| 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 |
$23,283.09
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$23,283.09
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$23,283.09
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$23,283.09
|
|
|
PROCEDURES FOR OBESITY
|
Facility
|
IP
|
$44,606.19
|
|
|
Service Code
|
APR-DRG 4034
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$44,606.19 |
| 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 |
$44,606.19
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$44,606.19
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$44,606.19
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$44,606.19
|
|
|
PROCEDURES FOR OBESITY
|
Facility
|
IP
|
$11,212.57
|
|
|
Service Code
|
APR-DRG 4031
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$11,212.57 |
| 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: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$11,212.57
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$11,212.57
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$11,212.57
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$11,212.57
|
|
|
PROCEDURES FOR OBESITY
|
Facility
|
IP
|
$13,910.31
|
|
|
Service Code
|
APR-DRG 4032
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$13,910.31 |
| 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 |
$13,910.31
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$13,910.31
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$13,910.31
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$13,910.31
|
|
|
PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SE
|
Facility
|
IP
|
$35,523.72
|
|
|
Service Code
|
APR-DRG 8503
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$35,523.72 |
| 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 |
$35,523.72
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$35,523.72
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$35,523.72
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$35,523.72
|
|
|
PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SE
|
Facility
|
IP
|
$79,736.99
|
|
|
Service Code
|
APR-DRG 8504
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$79,736.99 |
| 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 |
$79,736.99
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$79,736.99
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$79,736.99
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$79,736.99
|
|
|
PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SE
|
Facility
|
IP
|
$15,431.15
|
|
|
Service Code
|
APR-DRG 8501
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$15,431.15 |
| 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 |
$15,431.15
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$15,431.15
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$15,431.15
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$15,431.15
|
|
|
PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SE
|
Facility
|
IP
|
$24,264.00
|
|
|
Service Code
|
APR-DRG 8502
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$24,264.00 |
| 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 |
$24,264.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$24,264.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$24,264.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$24,264.00
|
|
|
prochlorperazine 10 mg/2 mL (5 mg/mL) solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 25021079002
|
|
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
|
|
|
prochlorperazine 10 mg/2 mL (5 mg/mL) solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 25021079002
|
|
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
|
|
|
prochlorperazine 10 mg/2 mL (5 mg/mL) solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J0780
|
|
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
|
|
|
prochlorperazine 10 mg/2 mL (5 mg/mL) solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J0780
|
|
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
|
|
|
prochlorperazine 10 mg tablet 1 Each BLIST PACK
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
NDC 50268068511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$3.37
|
| Rate for Payer: Aetna Workers' Compensation |
$3.37
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$3.31
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$3.31
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$3.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$3.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$3.77
|
| Rate for Payer: Cash Price |
$4.78
|
| Rate for Payer: Cigna Commercial |
$2.93
|
| Rate for Payer: Cigna Medicare Advantage |
$2.72
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$3.01
|
| Rate for Payer: Home State Health Plan Exchange |
$2.72
|
| Rate for Payer: Humana Medicare |
$3.58
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3.58
|
| Rate for Payer: Provider Network of America Commercial |
$3.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$3.15
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$4.78
|
|
|
prochlorperazine 10 mg tablet 1 Each BLIST PACK
|
Facility
|
IP
|
$4.78
|
|
|
Service Code
|
NDC 50268068511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.58 |
| 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 |
$4.78
|
| Rate for Payer: Cash Price |
$4.78
|
| 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 |
$3.58
|
| Rate for Payer: Provider Network of America Commercial |
$3.82
|
|
|
prochlorperazine 10 mg tablet 50 Each BLIST PACK
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
NDC 50268068515
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$3.37
|
| Rate for Payer: Aetna Workers' Compensation |
$3.37
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$3.31
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$3.31
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$3.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$3.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$3.77
|
| Rate for Payer: Cash Price |
$4.78
|
| Rate for Payer: Cigna Commercial |
$2.93
|
| Rate for Payer: Cigna Medicare Advantage |
$2.72
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$3.01
|
| Rate for Payer: Home State Health Plan Exchange |
$2.72
|
| Rate for Payer: Humana Medicare |
$3.58
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3.58
|
| Rate for Payer: Provider Network of America Commercial |
$3.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$3.15
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$4.78
|
|
|
prochlorperazine 10 mg tablet 50 Each BLIST PACK
|
Facility
|
IP
|
$4.78
|
|
|
Service Code
|
NDC 50268068515
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.58 |
| 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 |
$4.78
|
| Rate for Payer: Cash Price |
$4.78
|
| 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 |
$3.58
|
| Rate for Payer: Provider Network of America Commercial |
$3.82
|
|
|
Prochlorperazine Injection
|
Facility
|
IP
|
$114.45
|
|
|
Service Code
|
CPT J0780
|
| Hospital Charge Code |
Px0636J078001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.84 |
| 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 |
$114.45
|
| Rate for Payer: Cash Price |
$114.45
|
| 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 |
$85.84
|
| Rate for Payer: Provider Network of America Commercial |
$91.56
|
|
|
Prochlorperazine Injection
|
Facility
|
OP
|
$114.45
|
|
|
Service Code
|
CPT J0780
|
| Hospital Charge Code |
Px0636J078001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.24 |
| Max. Negotiated Rate |
$114.45 |
| Rate for Payer: Aetna Workers' Compensation |
$80.69
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$80.69
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$79.31
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$79.31
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$90.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$90.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$90.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$88.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$90.19
|
| Rate for Payer: Cash Price |
$114.45
|
| Rate for Payer: Cigna Commercial |
$70.04
|
| Rate for Payer: Cigna Medicare Advantage |
$65.24
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$72.10
|
| Rate for Payer: Home State Health Plan Exchange |
$65.24
|
| Rate for Payer: Humana Medicare |
$85.84
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$85.84
|
| Rate for Payer: Provider Network of America Commercial |
$91.56
|
| Rate for Payer: UnitedHealthcare Commercial |
$75.54
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$114.45
|
|
