|
REVISION OF HIP OR KNEE REPLACEMENT WITH CC
|
Facility
|
IP
|
$16,575.02
|
|
|
Service Code
|
MSDRG 467
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$16,575.02 |
| 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: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$16,575.02
|
|
|
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC
|
Facility
|
IP
|
$24,465.38
|
|
|
Service Code
|
MSDRG 466
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$24,465.38 |
| 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 |
$24,465.38
|
|
|
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$12,915.60
|
|
|
Service Code
|
MSDRG 468
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$12,915.60 |
| 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 |
$12,915.60
|
|
|
rho(D) immune globulin 1,500 unit (300 mcg)/2 mL syringe 2 mL Syringe
|
Facility
|
IP
|
$707.84
|
|
|
Service Code
|
NDC 44206030001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$530.88 |
| 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 |
$707.84
|
| Rate for Payer: Cash Price |
$707.84
|
| 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 |
$530.88
|
| Rate for Payer: Provider Network of America Commercial |
$566.27
|
|
|
rho(D) immune globulin 1,500 unit (300 mcg)/2 mL syringe 2 mL Syringe
|
Facility
|
OP
|
$707.84
|
|
|
Service Code
|
NDC 44206030090
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$403.47 |
| Max. Negotiated Rate |
$707.84 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$499.03
|
| Rate for Payer: Aetna Workers' Compensation |
$499.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$490.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$490.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$557.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$557.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$557.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$545.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$557.78
|
| Rate for Payer: Cash Price |
$707.84
|
| Rate for Payer: Cigna Commercial |
$433.20
|
| Rate for Payer: Cigna Medicare Advantage |
$403.47
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$445.94
|
| Rate for Payer: Home State Health Plan Exchange |
$403.47
|
| Rate for Payer: Humana Medicare |
$530.88
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$530.88
|
| Rate for Payer: Provider Network of America Commercial |
$566.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$467.17
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$707.84
|
|
|
rho(D) immune globulin 1,500 unit (300 mcg)/2 mL syringe 2 mL Syringe
|
Facility
|
OP
|
$707.84
|
|
|
Service Code
|
NDC 44206030001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$403.47 |
| Max. Negotiated Rate |
$707.84 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$499.03
|
| Rate for Payer: Aetna Workers' Compensation |
$499.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$490.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$490.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$557.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$557.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$557.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$545.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$557.78
|
| Rate for Payer: Cash Price |
$707.84
|
| Rate for Payer: Cigna Commercial |
$433.20
|
| Rate for Payer: Cigna Medicare Advantage |
$403.47
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$445.94
|
| Rate for Payer: Home State Health Plan Exchange |
$403.47
|
| Rate for Payer: Humana Medicare |
$530.88
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$530.88
|
| Rate for Payer: Provider Network of America Commercial |
$566.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$467.17
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$707.84
|
|
|
rho(D) immune globulin 1,500 unit (300 mcg)/2 mL syringe 2 mL Syringe
|
Facility
|
IP
|
$707.84
|
|
|
Service Code
|
HCPCS J2791
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$530.88 |
| 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 |
$707.84
|
| Rate for Payer: Cash Price |
$707.84
|
| 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 |
$530.88
|
| Rate for Payer: Provider Network of America Commercial |
$566.27
|
|
|
rho(D) immune globulin 1,500 unit (300 mcg)/2 mL syringe 2 mL Syringe
|
Facility
|
IP
|
$707.84
|
|
|
Service Code
|
NDC 44206030090
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$530.88 |
| 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 |
$707.84
|
| Rate for Payer: Cash Price |
$707.84
|
| 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 |
$530.88
|
| Rate for Payer: Provider Network of America Commercial |
$566.27
|
|
|
rho(D) immune globulin 1,500 unit (300 mcg)/2 mL syringe 2 mL Syringe
|
Facility
|
OP
|
$707.84
|
|
|
Service Code
|
HCPCS J2791
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$403.47 |
| Max. Negotiated Rate |
$707.84 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$499.03
|
| Rate for Payer: Aetna Workers' Compensation |
$499.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$490.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$490.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$557.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$557.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$557.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$545.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$557.78
|
| Rate for Payer: Cash Price |
$707.84
|
| Rate for Payer: Cigna Commercial |
$433.20
|
| Rate for Payer: Cigna Medicare Advantage |
$403.47
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$445.94
|
| Rate for Payer: Home State Health Plan Exchange |
$403.47
|
| Rate for Payer: Humana Medicare |
$530.88
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$530.88
|
| Rate for Payer: Provider Network of America Commercial |
$566.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$467.17
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$707.84
|
|
|
rho(D) immune globulin 1,500 unit (300 mcg) syringe 1 Each Syringe
|
Facility
|
IP
|
$492.00
|
|
|
Service Code
|
NDC 00562780500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$369.00 |
| 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 |
$492.00
|
| Rate for Payer: Cash Price |
$492.00
|
| 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 |
$369.00
|
| Rate for Payer: Provider Network of America Commercial |
$393.60
|
|
|
rho(D) immune globulin 1,500 unit (300 mcg) syringe 1 Each Syringe
|
Facility
|
OP
|
$492.00
|
|
|
Service Code
|
HCPCS J2790
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$280.44 |
| Max. Negotiated Rate |
$492.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$346.86
|
| Rate for Payer: Aetna Workers' Compensation |
$346.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$340.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$340.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$387.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$387.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$387.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$378.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$387.70
|
| Rate for Payer: Cash Price |
$492.00
|
| Rate for Payer: Cigna Commercial |
$301.10
|
| Rate for Payer: Cigna Medicare Advantage |
$280.44
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$309.96
|
| Rate for Payer: Home State Health Plan Exchange |
$280.44
|
| Rate for Payer: Humana Medicare |
$369.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$369.00
|
| Rate for Payer: Provider Network of America Commercial |
$393.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$324.72
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$492.00
|
|
|
rho(D) immune globulin 1,500 unit (300 mcg) syringe 1 Each Syringe
|
Facility
|
OP
|
$492.00
|
|
|
Service Code
|
NDC 00562780500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$280.44 |
| Max. Negotiated Rate |
$492.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$346.86
|
| Rate for Payer: Aetna Workers' Compensation |
$346.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$340.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$340.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$387.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$387.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$387.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$378.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$387.70
|
| Rate for Payer: Cash Price |
$492.00
|
| Rate for Payer: Cigna Commercial |
$301.10
|
| Rate for Payer: Cigna Medicare Advantage |
$280.44
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$309.96
|
| Rate for Payer: Home State Health Plan Exchange |
$280.44
|
| Rate for Payer: Humana Medicare |
$369.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$369.00
|
| Rate for Payer: Provider Network of America Commercial |
$393.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$324.72
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$492.00
|
|
|
rho(D) immune globulin 1,500 unit (300 mcg) syringe 1 Each Syringe
|
Facility
|
IP
|
$492.00
|
|
|
Service Code
|
HCPCS J2790
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$369.00 |
| 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 |
$492.00
|
| Rate for Payer: Cash Price |
$492.00
|
| 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 |
$369.00
|
| Rate for Payer: Provider Network of America Commercial |
$393.60
|
|
|
Rib Belt Universal
|
Facility
|
OP
|
$22.65
|
|
| Hospital Charge Code |
Px02700000052
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$22.65 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$15.97
|
| Rate for Payer: Aetna Workers' Compensation |
$15.97
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$15.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$15.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$17.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$17.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$17.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$17.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$17.85
|
| Rate for Payer: Cash Price |
$22.65
|
| Rate for Payer: Cigna Commercial |
$13.86
|
| Rate for Payer: Cigna Medicare Advantage |
$12.91
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$14.27
|
| Rate for Payer: Home State Health Plan Exchange |
$12.91
|
| Rate for Payer: Humana Medicare |
$16.99
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$16.99
|
| Rate for Payer: Provider Network of America Commercial |
$18.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.95
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$22.65
|
|
|
Rib Belt Universal
|
Facility
|
IP
|
$22.65
|
|
| Hospital Charge Code |
Px02700000052
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$16.99 |
| 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 |
$22.65
|
| Rate for Payer: Cash Price |
$22.65
|
| 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 |
$16.99
|
| Rate for Payer: Provider Network of America Commercial |
$18.12
|
|
|
rifAXIMin 550 mg tablet 60 Each BLIST PACK
|
Facility
|
OP
|
$268.97
|
|
|
Service Code
|
NDC 65649030303
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.31 |
| Max. Negotiated Rate |
$268.97 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$189.62
|
| Rate for Payer: Aetna Workers' Compensation |
$189.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$186.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$186.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$211.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$211.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$211.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$207.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$211.95
|
| Rate for Payer: Cash Price |
$268.97
|
| Rate for Payer: Cigna Commercial |
$164.61
|
| Rate for Payer: Cigna Medicare Advantage |
$153.31
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$169.45
|
| Rate for Payer: Home State Health Plan Exchange |
$153.31
|
| Rate for Payer: Humana Medicare |
$201.73
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$201.73
|
| Rate for Payer: Provider Network of America Commercial |
$215.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$177.52
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$268.97
|
|
|
rifAXIMin 550 mg tablet 60 Each BLIST PACK
|
Facility
|
IP
|
$268.97
|
|
|
Service Code
|
NDC 65649030303
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$201.73 |
| 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 |
$268.97
|
| Rate for Payer: Cash Price |
$268.97
|
| 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 |
$201.73
|
| Rate for Payer: Provider Network of America Commercial |
$215.18
|
|
|
risedronate 35 mg tablet 4 Each BLIST PACK
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 33342010937
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| 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 |
$18.75
|
| Rate for Payer: Provider Network of America Commercial |
$20.00
|
|
|
risedronate 35 mg tablet 4 Each BLIST PACK
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 33342010937
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$17.62
|
| Rate for Payer: Aetna Workers' Compensation |
$17.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$17.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$17.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$19.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$19.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$19.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$19.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$19.70
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$15.30
|
| Rate for Payer: Cigna Medicare Advantage |
$14.25
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$15.75
|
| Rate for Payer: Home State Health Plan Exchange |
$14.25
|
| Rate for Payer: Humana Medicare |
$18.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$18.75
|
| Rate for Payer: Provider Network of America Commercial |
$20.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$16.50
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$25.00
|
|
|
risperiDONE 1 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904635961
|
|
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
|
|
|
risperiDONE 1 mg tablet 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904635961
|
|
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
|
|
|
riTUXimab 10 mg/mL concentrate 10 mL Vial
|
Facility
|
IP
|
$3,758.08
|
|
|
Service Code
|
HCPCS J9312
|
|
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 |
$3,758.08
|
| Rate for Payer: Cash Price |
$3,758.08
|
| 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 |
$2,818.56
|
| Rate for Payer: Provider Network of America Commercial |
$3,006.46
|
|
|
riTUXimab 10 mg/mL concentrate 10 mL Vial
|
Facility
|
OP
|
$3,758.08
|
|
|
Service Code
|
HCPCS J9312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,142.11 |
| Max. Negotiated Rate |
$3,758.08 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2,649.45
|
| Rate for Payer: Aetna Workers' Compensation |
$2,649.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$2,604.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$2,604.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$2,961.37
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$2,961.37
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$2,961.37
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$2,893.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$2,961.37
|
| Rate for Payer: Cash Price |
$3,758.08
|
| Rate for Payer: Cigna Commercial |
$2,299.94
|
| Rate for Payer: Cigna Medicare Advantage |
$2,142.11
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2,367.59
|
| Rate for Payer: Home State Health Plan Exchange |
$2,142.11
|
| Rate for Payer: Humana Medicare |
$2,818.56
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,818.56
|
| Rate for Payer: Provider Network of America Commercial |
$3,006.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,480.33
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$3,758.08
|
|
|
riTUXimab 10 mg/mL concentrate 10 mL Vial
|
Facility
|
OP
|
$3,758.08
|
|
|
Service Code
|
NDC 50242005121
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,142.11 |
| Max. Negotiated Rate |
$3,758.08 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2,649.45
|
| Rate for Payer: Aetna Workers' Compensation |
$2,649.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$2,604.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$2,604.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$2,961.37
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$2,961.37
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$2,961.37
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$2,893.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$2,961.37
|
| Rate for Payer: Cash Price |
$3,758.08
|
| Rate for Payer: Cigna Commercial |
$2,299.94
|
| Rate for Payer: Cigna Medicare Advantage |
$2,142.11
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2,367.59
|
| Rate for Payer: Home State Health Plan Exchange |
$2,142.11
|
| Rate for Payer: Humana Medicare |
$2,818.56
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,818.56
|
| Rate for Payer: Provider Network of America Commercial |
$3,006.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,480.33
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$3,758.08
|
|
|
riTUXimab 10 mg/mL concentrate 10 mL Vial
|
Facility
|
IP
|
$3,758.08
|
|
|
Service Code
|
NDC 50242005121
|
|
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 |
$3,758.08
|
| Rate for Payer: Cash Price |
$3,758.08
|
| 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 |
$2,818.56
|
| Rate for Payer: Provider Network of America Commercial |
$3,006.46
|
|
