|
riTUXimab 10 mg/mL concentrate 50 mL Vial
|
Facility
|
IP
|
$18,790.40
|
|
|
Service Code
|
NDC 50242005306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$15,032.32 |
| 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 |
$18,790.40
|
| Rate for Payer: Cash Price |
$18,790.40
|
| 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 |
$14,092.80
|
| Rate for Payer: Provider Network of America Commercial |
$15,032.32
|
|
|
riTUXimab 10 mg/mL concentrate 50 mL Vial
|
Facility
|
IP
|
$18,790.40
|
|
|
Service Code
|
HCPCS J9312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$15,032.32 |
| 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 |
$18,790.40
|
| Rate for Payer: Cash Price |
$18,790.40
|
| 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 |
$14,092.80
|
| Rate for Payer: Provider Network of America Commercial |
$15,032.32
|
|
|
riTUXimab 10 mg/mL concentrate 50 mL Vial
|
Facility
|
OP
|
$18,790.40
|
|
|
Service Code
|
HCPCS J9312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10,710.53 |
| Max. Negotiated Rate |
$18,790.40 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$13,247.23
|
| Rate for Payer: Aetna Workers' Compensation |
$13,247.23
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$13,021.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$13,021.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$14,806.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$14,806.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$14,806.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$14,468.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$14,806.84
|
| Rate for Payer: Cash Price |
$18,790.40
|
| Rate for Payer: Cigna Commercial |
$11,499.72
|
| Rate for Payer: Cigna Medicare Advantage |
$10,710.53
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$11,837.95
|
| Rate for Payer: Home State Health Plan Exchange |
$10,710.53
|
| Rate for Payer: Humana Medicare |
$14,092.80
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$14,092.80
|
| Rate for Payer: Provider Network of America Commercial |
$15,032.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$12,401.66
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$18,790.40
|
|
|
riTUXimab 10 mg/mL concentrate 50 mL Vial
|
Facility
|
OP
|
$18,790.40
|
|
|
Service Code
|
NDC 50242005306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10,710.53 |
| Max. Negotiated Rate |
$18,790.40 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$13,247.23
|
| Rate for Payer: Aetna Workers' Compensation |
$13,247.23
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$13,021.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$13,021.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$14,806.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$14,806.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$14,806.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$14,468.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$14,806.84
|
| Rate for Payer: Cash Price |
$18,790.40
|
| Rate for Payer: Cigna Commercial |
$11,499.72
|
| Rate for Payer: Cigna Medicare Advantage |
$10,710.53
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$11,837.95
|
| Rate for Payer: Home State Health Plan Exchange |
$10,710.53
|
| Rate for Payer: Humana Medicare |
$14,092.80
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$14,092.80
|
| Rate for Payer: Provider Network of America Commercial |
$15,032.32
|
| Rate for Payer: UnitedHealthcare Commercial |
$12,401.66
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$18,790.40
|
|
|
riTUXimab-abbs 10 mg/mL solution 10 mL Vial
|
Facility
|
IP
|
$3,382.20
|
|
|
Service Code
|
NDC 63459010310
|
|
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 |
$3,382.20
|
| Rate for Payer: Cash Price |
$3,382.20
|
| 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 |
$2,536.65
|
| Rate for Payer: Provider Network of America Commercial |
$2,705.76
|
|
|
riTUXimab-abbs 10 mg/mL solution 10 mL Vial
|
Facility
|
OP
|
$3,382.20
|
|
|
Service Code
|
NDC 63459010310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,927.85 |
| Max. Negotiated Rate |
$3,382.20 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2,384.45
|
| Rate for Payer: Aetna Workers' Compensation |
$2,384.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$2,343.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$2,343.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$2,665.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$2,665.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$2,665.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$2,604.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$2,665.17
|
| Rate for Payer: Cash Price |
$3,382.20
|
| Rate for Payer: Cigna Commercial |
$2,069.91
|
| Rate for Payer: Cigna Medicare Advantage |
$1,927.85
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2,130.79
|
| Rate for Payer: Home State Health Plan Exchange |
$1,927.85
|
| Rate for Payer: Humana Medicare |
$2,536.65
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,536.65
|
| Rate for Payer: Provider Network of America Commercial |
$2,705.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,232.25
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$3,382.20
|
|
|
riTUXimab-abbs 10 mg/mL solution 10 mL Vial
|
Facility
|
IP
|
$3,382.20
|
|
|
Service Code
|
HCPCS Q5115
|
|
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 |
$3,382.20
|
| Rate for Payer: Cash Price |
$3,382.20
|
| 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 |
$2,536.65
|
| Rate for Payer: Provider Network of America Commercial |
$2,705.76
|
|
|
riTUXimab-abbs 10 mg/mL solution 10 mL Vial
|
Facility
|
OP
|
$3,382.20
|
|
|
Service Code
|
HCPCS Q5115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,927.85 |
| Max. Negotiated Rate |
$3,382.20 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2,384.45
|
| Rate for Payer: Aetna Workers' Compensation |
$2,384.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$2,343.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$2,343.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$2,665.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$2,665.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$2,665.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$2,604.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$2,665.17
|
| Rate for Payer: Cash Price |
$3,382.20
|
| Rate for Payer: Cigna Commercial |
$2,069.91
|
| Rate for Payer: Cigna Medicare Advantage |
$1,927.85
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2,130.79
|
| Rate for Payer: Home State Health Plan Exchange |
$1,927.85
|
| Rate for Payer: Humana Medicare |
$2,536.65
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,536.65
|
| Rate for Payer: Provider Network of America Commercial |
$2,705.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,232.25
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$3,382.20
|
|
|
riTUXimab-abbs 10 mg/mL solution 50 mL Vial
|
Facility
|
IP
|
$16,911.00
|
|
|
Service Code
|
HCPCS Q5115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$13,528.80 |
| 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 |
$16,911.00
|
| Rate for Payer: Cash Price |
$16,911.00
|
| 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 |
$12,683.25
|
| Rate for Payer: Provider Network of America Commercial |
$13,528.80
|
|
|
riTUXimab-abbs 10 mg/mL solution 50 mL Vial
|
Facility
|
OP
|
$16,911.00
|
|
|
Service Code
|
NDC 63459010450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9,639.27 |
| Max. Negotiated Rate |
$16,911.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$11,922.25
|
| Rate for Payer: Aetna Workers' Compensation |
$11,922.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$11,719.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$11,719.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$13,325.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$13,325.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$13,325.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$13,021.47
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$13,325.87
|
| Rate for Payer: Cash Price |
$16,911.00
|
| Rate for Payer: Cigna Commercial |
$10,349.53
|
| Rate for Payer: Cigna Medicare Advantage |
$9,639.27
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$10,653.93
|
| Rate for Payer: Home State Health Plan Exchange |
$9,639.27
|
| Rate for Payer: Humana Medicare |
$12,683.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$12,683.25
|
| Rate for Payer: Provider Network of America Commercial |
$13,528.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$11,161.26
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$16,911.00
|
|
|
riTUXimab-abbs 10 mg/mL solution 50 mL Vial
|
Facility
|
IP
|
$16,911.00
|
|
|
Service Code
|
NDC 63459010450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$13,528.80 |
| 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 |
$16,911.00
|
| Rate for Payer: Cash Price |
$16,911.00
|
| 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 |
$12,683.25
|
| Rate for Payer: Provider Network of America Commercial |
$13,528.80
|
|
|
riTUXimab-abbs 10 mg/mL solution 50 mL Vial
|
Facility
|
OP
|
$16,911.00
|
|
|
Service Code
|
HCPCS Q5115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9,639.27 |
| Max. Negotiated Rate |
$16,911.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$11,922.25
|
| Rate for Payer: Aetna Workers' Compensation |
$11,922.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$11,719.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$11,719.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$13,325.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$13,325.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$13,325.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$13,021.47
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$13,325.87
|
| Rate for Payer: Cash Price |
$16,911.00
|
| Rate for Payer: Cigna Commercial |
$10,349.53
|
| Rate for Payer: Cigna Medicare Advantage |
$9,639.27
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$10,653.93
|
| Rate for Payer: Home State Health Plan Exchange |
$9,639.27
|
| Rate for Payer: Humana Medicare |
$12,683.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$12,683.25
|
| Rate for Payer: Provider Network of America Commercial |
$13,528.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$11,161.26
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$16,911.00
|
|
|
riTUXimab-pvvr 10 mg/mL solution 10 mL Vial
|
Facility
|
IP
|
$2,867.20
|
|
|
Service Code
|
HCPCS Q5119
|
|
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 |
$2,867.20
|
| Rate for Payer: Cash Price |
$2,867.20
|
| 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 |
$2,150.40
|
| Rate for Payer: Provider Network of America Commercial |
$2,293.76
|
|
|
riTUXimab-pvvr 10 mg/mL solution 10 mL Vial
|
Facility
|
OP
|
$2,867.20
|
|
|
Service Code
|
HCPCS Q5119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,634.30 |
| Max. Negotiated Rate |
$2,867.20 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2,021.38
|
| Rate for Payer: Aetna Workers' Compensation |
$2,021.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,986.97
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,986.97
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$2,259.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$2,259.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$2,259.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$2,207.74
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$2,259.35
|
| Rate for Payer: Cash Price |
$2,867.20
|
| Rate for Payer: Cigna Commercial |
$1,754.73
|
| Rate for Payer: Cigna Medicare Advantage |
$1,634.30
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,806.34
|
| Rate for Payer: Home State Health Plan Exchange |
$1,634.30
|
| Rate for Payer: Humana Medicare |
$2,150.40
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,150.40
|
| Rate for Payer: Provider Network of America Commercial |
$2,293.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,892.35
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$2,867.20
|
|
|
riTUXimab-pvvr 10 mg/mL solution 10 mL Vial
|
Facility
|
IP
|
$2,867.20
|
|
|
Service Code
|
NDC 00069023801
|
|
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 |
$2,867.20
|
| Rate for Payer: Cash Price |
$2,867.20
|
| 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 |
$2,150.40
|
| Rate for Payer: Provider Network of America Commercial |
$2,293.76
|
|
|
riTUXimab-pvvr 10 mg/mL solution 10 mL Vial
|
Facility
|
OP
|
$2,867.20
|
|
|
Service Code
|
NDC 00069023801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,634.30 |
| Max. Negotiated Rate |
$2,867.20 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2,021.38
|
| Rate for Payer: Aetna Workers' Compensation |
$2,021.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,986.97
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,986.97
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$2,259.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$2,259.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$2,259.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$2,207.74
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$2,259.35
|
| Rate for Payer: Cash Price |
$2,867.20
|
| Rate for Payer: Cigna Commercial |
$1,754.73
|
| Rate for Payer: Cigna Medicare Advantage |
$1,634.30
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,806.34
|
| Rate for Payer: Home State Health Plan Exchange |
$1,634.30
|
| Rate for Payer: Humana Medicare |
$2,150.40
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,150.40
|
| Rate for Payer: Provider Network of America Commercial |
$2,293.76
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,892.35
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$2,867.20
|
|
|
riTUXimab-pvvr 10 mg/mL solution 50 mL Vial
|
Facility
|
IP
|
$14,336.00
|
|
|
Service Code
|
HCPCS Q5119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$11,468.80 |
| 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 |
$14,336.00
|
| Rate for Payer: Cash Price |
$14,336.00
|
| 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 |
$10,752.00
|
| Rate for Payer: Provider Network of America Commercial |
$11,468.80
|
|
|
riTUXimab-pvvr 10 mg/mL solution 50 mL Vial
|
Facility
|
IP
|
$14,336.00
|
|
|
Service Code
|
NDC 00069024901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$11,468.80 |
| 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 |
$14,336.00
|
| Rate for Payer: Cash Price |
$14,336.00
|
| 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 |
$10,752.00
|
| Rate for Payer: Provider Network of America Commercial |
$11,468.80
|
|
|
riTUXimab-pvvr 10 mg/mL solution 50 mL Vial
|
Facility
|
OP
|
$14,336.00
|
|
|
Service Code
|
HCPCS Q5119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,171.52 |
| Max. Negotiated Rate |
$14,336.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$10,106.88
|
| Rate for Payer: Aetna Workers' Compensation |
$10,106.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$9,934.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$9,934.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$11,296.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$11,296.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$11,296.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$11,038.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$11,296.77
|
| Rate for Payer: Cash Price |
$14,336.00
|
| Rate for Payer: Cigna Commercial |
$8,773.63
|
| Rate for Payer: Cigna Medicare Advantage |
$8,171.52
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$9,031.68
|
| Rate for Payer: Home State Health Plan Exchange |
$8,171.52
|
| Rate for Payer: Humana Medicare |
$10,752.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$10,752.00
|
| Rate for Payer: Provider Network of America Commercial |
$11,468.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$9,461.76
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$14,336.00
|
|
|
riTUXimab-pvvr 10 mg/mL solution 50 mL Vial
|
Facility
|
OP
|
$14,336.00
|
|
|
Service Code
|
NDC 00069024901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,171.52 |
| Max. Negotiated Rate |
$14,336.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$10,106.88
|
| Rate for Payer: Aetna Workers' Compensation |
$10,106.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$9,934.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$9,934.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$11,296.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$11,296.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$11,296.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$11,038.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$11,296.77
|
| Rate for Payer: Cash Price |
$14,336.00
|
| Rate for Payer: Cigna Commercial |
$8,773.63
|
| Rate for Payer: Cigna Medicare Advantage |
$8,171.52
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$9,031.68
|
| Rate for Payer: Home State Health Plan Exchange |
$8,171.52
|
| Rate for Payer: Humana Medicare |
$10,752.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$10,752.00
|
| Rate for Payer: Provider Network of America Commercial |
$11,468.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$9,461.76
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$14,336.00
|
|
|
rivaroxaban 10 mg tablet 100 Each BLIST PACK
|
Facility
|
IP
|
$81.58
|
|
|
Service Code
|
NDC 50458058010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.19 |
| 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 |
$81.58
|
| Rate for Payer: Cash Price |
$81.58
|
| 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 |
$61.19
|
| Rate for Payer: Provider Network of America Commercial |
$65.26
|
|
|
rivaroxaban 10 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$81.58
|
|
|
Service Code
|
NDC 50458058010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$81.58 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$57.51
|
| Rate for Payer: Aetna Workers' Compensation |
$57.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$56.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$56.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$64.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$64.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$64.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$62.82
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$64.29
|
| Rate for Payer: Cash Price |
$81.58
|
| Rate for Payer: Cigna Commercial |
$49.93
|
| Rate for Payer: Cigna Medicare Advantage |
$46.50
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$51.40
|
| Rate for Payer: Home State Health Plan Exchange |
$46.50
|
| Rate for Payer: Humana Medicare |
$61.19
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$61.19
|
| Rate for Payer: Provider Network of America Commercial |
$65.26
|
| Rate for Payer: UnitedHealthcare Commercial |
$53.84
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$81.58
|
|
|
rivaroxaban 15 mg tablet 100 Each BLIST PACK
|
Facility
|
IP
|
$81.58
|
|
|
Service Code
|
NDC 50458057810
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.19 |
| 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 |
$81.58
|
| Rate for Payer: Cash Price |
$81.58
|
| 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 |
$61.19
|
| Rate for Payer: Provider Network of America Commercial |
$65.26
|
|
|
rivaroxaban 15 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$81.58
|
|
|
Service Code
|
NDC 50458057810
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$81.58 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$57.51
|
| Rate for Payer: Aetna Workers' Compensation |
$57.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$56.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$56.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$64.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$64.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$64.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$62.82
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$64.29
|
| Rate for Payer: Cash Price |
$81.58
|
| Rate for Payer: Cigna Commercial |
$49.93
|
| Rate for Payer: Cigna Medicare Advantage |
$46.50
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$51.40
|
| Rate for Payer: Home State Health Plan Exchange |
$46.50
|
| Rate for Payer: Humana Medicare |
$61.19
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$61.19
|
| Rate for Payer: Provider Network of America Commercial |
$65.26
|
| Rate for Payer: UnitedHealthcare Commercial |
$53.84
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$81.58
|
|
|
rivaroxaban 15 mg tablet 1 Each BLIST PACK
|
Facility
|
IP
|
$81.58
|
|
|
Service Code
|
NDC 50458057801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.19 |
| 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 |
$81.58
|
| Rate for Payer: Cash Price |
$81.58
|
| 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 |
$61.19
|
| Rate for Payer: Provider Network of America Commercial |
$65.26
|
|
