|
PULMONARY EMBOLISM
|
Facility
|
IP
|
$7,608.79
|
|
|
Service Code
|
APR-DRG 1342
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$7,608.79 |
| 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 |
$7,608.79
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$7,608.79
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$7,608.79
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$7,608.79
|
|
|
PULMONARY EMBOLISM
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
APR-DRG 1341
|
| 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 |
$5,698.74
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$5,698.74
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$5,698.74
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$5,698.74
|
|
|
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE
|
Facility
|
IP
|
$6,455.92
|
|
|
Service Code
|
MSDRG 175
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,455.92 |
| 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 |
$6,455.92
|
|
|
PULMONARY EMBOLISM WITHOUT MCC
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 176
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Humana Medicare |
$3,783.50
|
| 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
|
|
|
Pulmonary Ventilation & Perfusion Imaging
|
Facility
|
IP
|
$141.96
|
|
|
Service Code
|
CPT 78582
|
| Hospital Charge Code |
Px09727858201
|
|
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
|
|
|
Pulmonary Ventilation & Perfusion Imaging
|
Facility
|
OP
|
$141.96
|
|
|
Service Code
|
CPT 78582
|
| Hospital Charge Code |
Px09727858201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$80.92 |
| Max. Negotiated Rate |
$740.06 |
| 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 |
$685.24
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$89.43
|
| Rate for Payer: Healthy Blue Medicaid |
$740.06
|
| Rate for Payer: Home State Health Plan Exchange |
$80.92
|
| Rate for Payer: Home State Health Plan Medicaid |
$685.24
|
| Rate for Payer: Humana Medicare |
$106.47
|
| Rate for Payer: Mercy CarePlus Medicaid |
$685.24
|
| 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 |
$515.89
|
|
|
Puracol Plus Ag Silver
|
Facility
|
OP
|
$66.96
|
|
|
Service Code
|
CPT A6022
|
| Hospital Charge Code |
Px0270A602201
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$38.17 |
| Max. Negotiated Rate |
$66.96 |
| Rate for Payer: Humana Medicare |
$50.22
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$47.21
|
| Rate for Payer: Aetna Workers' Compensation |
$47.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$46.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$46.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$52.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$52.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$52.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$51.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$52.76
|
| Rate for Payer: Cash Price |
$66.96
|
| Rate for Payer: Cigna Commercial |
$40.98
|
| Rate for Payer: Cigna Medicare Advantage |
$38.17
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$42.18
|
| Rate for Payer: Home State Health Plan Exchange |
$38.17
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$50.22
|
| Rate for Payer: Provider Network of America Commercial |
$53.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$44.19
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$66.96
|
|
|
Puracol Plus Ag Silver
|
Facility
|
IP
|
$66.96
|
|
|
Service Code
|
CPT A6022
|
| Hospital Charge Code |
Px0270A602201
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$50.22 |
| 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 |
$66.96
|
| Rate for Payer: Cash Price |
$66.96
|
| 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 |
$50.22
|
| Rate for Payer: Provider Network of America Commercial |
$53.57
|
|
|
pyridoxine (vitamin B6) 100 mg tablet 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50268085911
|
|
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
|
|
|
pyridoxine (vitamin B6) 100 mg tablet 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50268085911
|
|
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
|
|
|
pyridoxine (vitamin B6) 100 mg tablet 50 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50268085915
|
|
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
|
|
|
pyridoxine (vitamin B6) 100 mg tablet 50 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50268085915
|
|
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
|
|
|
Quant Drug Not Elsewhere Specified - Carbamazepine
|
Facility
|
OP
|
$227.85
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
Px03018029939
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.69 |
| Max. Negotiated Rate |
$182.28 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$160.63
|
| Rate for Payer: Aetna Workers' Compensation |
$160.63
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$157.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$157.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$179.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$179.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$179.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$175.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$179.55
|
| Rate for Payer: Cash Price |
$227.85
|
| Rate for Payer: Cash Price |
$227.85
|
| Rate for Payer: Cigna Commercial |
$119.39
|
| Rate for Payer: Cigna Medicare Advantage |
$129.87
|
| Rate for Payer: Family Health Partners Medicaid |
$23.49
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$143.55
|
| Rate for Payer: Healthy Blue Medicaid |
$25.37
|
| Rate for Payer: Home State Health Plan Exchange |
$129.87
|
| Rate for Payer: Home State Health Plan Medicaid |
$23.49
|
| Rate for Payer: Humana Medicare |
$170.89
|
| Rate for Payer: Mercy CarePlus Medicaid |
$23.49
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$170.89
|
| Rate for Payer: Provider Network of America Commercial |
$182.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$150.38
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$18.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.69
|
|
|
Quant Drug Not Elsewhere Specified - Carbamazepine
|
Facility
|
IP
|
$227.85
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
Px03018029939
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$170.89 |
| 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 |
$227.85
|
| Rate for Payer: Cash Price |
$227.85
|
| 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 |
$170.89
|
| Rate for Payer: Provider Network of America Commercial |
$182.28
|
|
|
QUEtiapine 100 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904664061
|
|
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
|
|
|
QUEtiapine 100 mg tablet 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904664061
|
|
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
|
|
|
QUEtiapine 25 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904663861
|
|
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
|
|
|
QUEtiapine 25 mg tablet 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904663861
|
|
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
|
|
|
QUEtiapine 25 mg tablet 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687032711
|
|
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
|
|
|
QUEtiapine 25 mg tablet 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687032711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: UnitedHealthcare Commercial |
$2.64
|
| 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 Individual Exchange |
$4.00
|
|
|
rabies immune globulin (PF) 300 unit/mL solution 1 mL Vial
|
Facility
|
OP
|
$2,776.44
|
|
|
Service Code
|
CPT 90375
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,582.57 |
| Max. Negotiated Rate |
$2,776.44 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,957.39
|
| Rate for Payer: Aetna Workers' Compensation |
$1,957.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,924.07
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,924.07
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$2,187.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$2,187.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$2,187.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$2,137.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$2,187.83
|
| Rate for Payer: Cash Price |
$2,776.44
|
| Rate for Payer: Cigna Commercial |
$1,699.18
|
| Rate for Payer: Cigna Medicare Advantage |
$1,582.57
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,749.16
|
| Rate for Payer: Home State Health Plan Exchange |
$1,582.57
|
| Rate for Payer: Humana Medicare |
$2,082.33
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,082.33
|
| Rate for Payer: Provider Network of America Commercial |
$2,221.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,832.45
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$2,776.44
|
|
|
rabies immune globulin (PF) 300 unit/mL solution 1 mL Vial
|
Facility
|
IP
|
$2,776.44
|
|
|
Service Code
|
CPT 90375
|
|
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 |
$2,776.44
|
| Rate for Payer: Cash Price |
$2,776.44
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,082.33
|
| Rate for Payer: Provider Network of America Commercial |
$2,221.15
|
|
|
rabies immune globulin (PF) 300 unit/mL solution 1 mL Vial
|
Facility
|
IP
|
$2,776.44
|
|
|
Service Code
|
NDC 13533031801
|
|
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 |
$2,776.44
|
| Rate for Payer: Cash Price |
$2,776.44
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,082.33
|
| Rate for Payer: Provider Network of America Commercial |
$2,221.15
|
|
|
rabies immune globulin (PF) 300 unit/mL solution 1 mL Vial
|
Facility
|
OP
|
$2,776.44
|
|
|
Service Code
|
NDC 13533031801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,582.57 |
| Max. Negotiated Rate |
$2,776.44 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,957.39
|
| Rate for Payer: Aetna Workers' Compensation |
$1,957.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,924.07
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,924.07
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$2,187.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$2,187.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$2,187.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$2,137.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$2,187.83
|
| Rate for Payer: Cash Price |
$2,776.44
|
| Rate for Payer: Cigna Commercial |
$1,699.18
|
| Rate for Payer: Cigna Medicare Advantage |
$1,582.57
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,749.16
|
| Rate for Payer: Home State Health Plan Exchange |
$1,582.57
|
| Rate for Payer: Humana Medicare |
$2,082.33
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,082.33
|
| Rate for Payer: Provider Network of America Commercial |
$2,221.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,832.45
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$2,776.44
|
|
|
rabies immune globulin (PF) 300 unit/mL solution 3 mL Vial
|
Facility
|
OP
|
$8,329.32
|
|
|
Service Code
|
NDC 13533031803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,747.71 |
| Max. Negotiated Rate |
$8,329.32 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5,872.17
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$11,513.99
|
| Rate for Payer: Aetna Workers' Compensation |
$11,513.99
|
| Rate for Payer: Aetna Workers' Compensation |
$5,872.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$11,318.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5,772.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$11,318.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5,772.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$6,563.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$12,869.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$12,869.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$6,563.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$6,563.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$12,869.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$6,413.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$12,575.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$12,869.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$6,563.50
|
| Rate for Payer: Cash Price |
$8,329.32
|
| Rate for Payer: Cash Price |
$16,331.90
|
| Rate for Payer: Cigna Commercial |
$9,995.12
|
| Rate for Payer: Cigna Commercial |
$5,097.54
|
| Rate for Payer: Cigna Medicare Advantage |
$4,747.71
|
| Rate for Payer: Cigna Medicare Advantage |
$9,309.18
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$5,247.47
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$10,289.10
|
| Rate for Payer: Home State Health Plan Exchange |
$9,309.18
|
| Rate for Payer: Home State Health Plan Exchange |
$4,747.71
|
| Rate for Payer: Humana Medicare |
$6,246.99
|
| Rate for Payer: Humana Medicare |
$12,248.92
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$12,248.92
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$6,246.99
|
| Rate for Payer: Provider Network of America Commercial |
$6,663.46
|
| Rate for Payer: Provider Network of America Commercial |
$13,065.52
|
| Rate for Payer: UnitedHealthcare Commercial |
$10,779.05
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,497.35
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$16,331.90
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$8,329.32
|
|
