|
Slp Stdy Unatnd W/Hrt Rate/O2 Sat/Resp/Slp Time
|
Facility
|
OP
|
$413.70
|
|
|
Service Code
|
CPT 95800
|
| Hospital Charge Code |
Px07409580001
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$205.16 |
| Max. Negotiated Rate |
$413.70 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$291.66
|
| Rate for Payer: Aetna Workers' Compensation |
$291.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$286.69
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$286.69
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$326.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$326.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$326.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$318.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$326.00
|
| Rate for Payer: Cash Price |
$413.70
|
| Rate for Payer: Cash Price |
$413.70
|
| Rate for Payer: Cigna Commercial |
$253.18
|
| Rate for Payer: Cigna Medicare Advantage |
$235.81
|
| Rate for Payer: Family Health Partners Medicaid |
$272.51
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$260.63
|
| Rate for Payer: Healthy Blue Medicaid |
$294.31
|
| Rate for Payer: Home State Health Plan Exchange |
$235.81
|
| Rate for Payer: Home State Health Plan Medicaid |
$272.51
|
| Rate for Payer: Humana Medicare |
$310.27
|
| Rate for Payer: Mercy CarePlus Medicaid |
$272.51
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$310.27
|
| Rate for Payer: Provider Network of America Commercial |
$330.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$273.04
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$413.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$205.16
|
|
|
Slp Stdy Unatnd W/Hrt Rate/O2 Sat/Resp/Slp Time
|
Professional
|
Both
|
$413.70
|
|
|
Service Code
|
CPT 95800
|
| Hospital Charge Code |
Px00000095800
|
| Min. Negotiated Rate |
$157.30 |
| Max. Negotiated Rate |
$157.30 |
| Rate for Payer: Cash Price |
$413.70
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$157.30
|
|
|
Snap Cartidge 125mmhg W/ Reset
|
Facility
|
IP
|
$1,065.20
|
|
|
Service Code
|
HCPCS A9272
|
| Hospital Charge Code |
Px0272A927202
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$798.90 |
| 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 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 |
$1,065.20
|
| Rate for Payer: Cash Price |
$1,065.20
|
| 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 |
$798.90
|
| Rate for Payer: Provider Network of America Commercial |
$852.16
|
|
|
Snap Cartidge 125mmhg W/ Reset
|
Facility
|
OP
|
$1,065.20
|
|
|
Service Code
|
HCPCS A9272
|
| Hospital Charge Code |
Px0272A927202
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$607.16 |
| Max. Negotiated Rate |
$1,065.20 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$750.97
|
| Rate for Payer: Aetna Workers' Compensation |
$750.97
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$738.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$738.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$839.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$839.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$839.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$820.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$839.38
|
| Rate for Payer: Cash Price |
$1,065.20
|
| Rate for Payer: Cigna Commercial |
$651.90
|
| Rate for Payer: Cigna Medicare Advantage |
$607.16
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$671.08
|
| Rate for Payer: Home State Health Plan Exchange |
$607.16
|
| Rate for Payer: Humana Medicare |
$798.90
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$798.90
|
| Rate for Payer: Provider Network of America Commercial |
$852.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$703.03
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,065.20
|
|
|
Snap Securring
|
Facility
|
IP
|
$1,065.20
|
|
|
Service Code
|
HCPCS A9272
|
| Hospital Charge Code |
Px0272A927201
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$798.90 |
| 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 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 |
$1,065.20
|
| Rate for Payer: Cash Price |
$1,065.20
|
| 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 |
$798.90
|
| Rate for Payer: Provider Network of America Commercial |
$852.16
|
|
|
Snap Securring
|
Facility
|
OP
|
$1,065.20
|
|
|
Service Code
|
HCPCS A9272
|
| Hospital Charge Code |
Px0272A927201
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$607.16 |
| Max. Negotiated Rate |
$1,065.20 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$750.97
|
| Rate for Payer: Aetna Workers' Compensation |
$750.97
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$738.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$738.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$839.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$839.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$839.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$820.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$839.38
|
| Rate for Payer: Cash Price |
$1,065.20
|
| Rate for Payer: Cigna Commercial |
$651.90
|
| Rate for Payer: Cigna Medicare Advantage |
$607.16
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$671.08
|
| Rate for Payer: Home State Health Plan Exchange |
$607.16
|
| Rate for Payer: Humana Medicare |
$798.90
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$798.90
|
| Rate for Payer: Provider Network of America Commercial |
$852.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$703.03
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,065.20
|
|
|
So Acro Clav Can Web Prefab Ots Pr1
|
Facility
|
OP
|
$150.50
|
|
|
Service Code
|
CPT L3670
|
| Hospital Charge Code |
Px0274L367004
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$85.78 |
| Max. Negotiated Rate |
$150.50 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$106.10
|
| Rate for Payer: Aetna Workers' Compensation |
$106.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$104.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$104.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$118.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$118.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$118.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$115.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$118.59
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cigna Commercial |
$92.11
|
| Rate for Payer: Cigna Medicare Advantage |
$85.78
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$94.81
|
| Rate for Payer: Home State Health Plan Exchange |
$85.78
|
| Rate for Payer: Humana Medicare |
$112.88
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$112.88
|
| Rate for Payer: Provider Network of America Commercial |
$120.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$99.33
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$150.50
|
|
|
So Acro Clav Can Web Prefab Ots Pr1
|
Facility
|
IP
|
$150.50
|
|
|
Service Code
|
CPT L3670
|
| Hospital Charge Code |
Px0274L367004
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$112.88 |
| 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 |
$150.50
|
| Rate for Payer: Cash Price |
$150.50
|
| 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 |
$112.88
|
| Rate for Payer: Provider Network of America Commercial |
$120.40
|
|
|
So Acro Clav Can Web Prefab Ots Pr10
|
Facility
|
OP
|
$150.50
|
|
|
Service Code
|
CPT L3670
|
| Hospital Charge Code |
Px0274L367002
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$85.78 |
| Max. Negotiated Rate |
$150.50 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$106.10
|
| Rate for Payer: Aetna Workers' Compensation |
$106.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$104.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$104.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$118.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$118.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$118.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$115.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$118.59
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cigna Commercial |
$92.11
|
| Rate for Payer: Cigna Medicare Advantage |
$85.78
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$94.81
|
| Rate for Payer: Home State Health Plan Exchange |
$85.78
|
| Rate for Payer: Humana Medicare |
$112.88
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$112.88
|
| Rate for Payer: Provider Network of America Commercial |
$120.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$99.33
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$150.50
|
|
|
So Acro Clav Can Web Prefab Ots Pr10
|
Facility
|
IP
|
$150.50
|
|
|
Service Code
|
CPT L3670
|
| Hospital Charge Code |
Px0274L367002
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$112.88 |
| 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 |
$150.50
|
| Rate for Payer: Cash Price |
$150.50
|
| 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 |
$112.88
|
| Rate for Payer: Provider Network of America Commercial |
$120.40
|
|
|
So acro/clav can web pre ots
|
Facility
|
OP
|
$150.50
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
Px0274L367001
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$85.78 |
| Max. Negotiated Rate |
$150.50 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$106.10
|
| Rate for Payer: Aetna Workers' Compensation |
$106.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$104.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$104.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$118.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$118.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$118.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$115.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$118.59
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cigna Commercial |
$92.11
|
| Rate for Payer: Cigna Medicare Advantage |
$85.78
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$94.81
|
| Rate for Payer: Home State Health Plan Exchange |
$85.78
|
| Rate for Payer: Humana Medicare |
$112.88
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$112.88
|
| Rate for Payer: Provider Network of America Commercial |
$120.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$99.33
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$150.50
|
|
|
So acro/clav can web pre ots
|
Facility
|
IP
|
$150.50
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
Px0274L367001
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$112.88 |
| 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 |
$150.50
|
| Rate for Payer: Cash Price |
$150.50
|
| 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 |
$112.88
|
| Rate for Payer: Provider Network of America Commercial |
$120.40
|
|
|
sodium bicarbonate 4.2 % (0.5 mEq/mL) syringe 10 mL Syringe
|
Facility
|
IP
|
$88.48
|
|
|
Service Code
|
NDC 00409553424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.36 |
| 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 |
$88.48
|
| Rate for Payer: Cash Price |
$88.48
|
| 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 |
$66.36
|
| Rate for Payer: Provider Network of America Commercial |
$70.78
|
|
|
sodium bicarbonate 4.2 % (0.5 mEq/mL) syringe 10 mL Syringe
|
Facility
|
OP
|
$88.48
|
|
|
Service Code
|
NDC 00409553424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.43 |
| Max. Negotiated Rate |
$88.48 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$62.38
|
| Rate for Payer: Aetna Workers' Compensation |
$62.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$61.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$61.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$69.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$69.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$69.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$68.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$69.72
|
| Rate for Payer: Cash Price |
$88.48
|
| Rate for Payer: Cigna Commercial |
$54.15
|
| Rate for Payer: Cigna Medicare Advantage |
$50.43
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$55.74
|
| Rate for Payer: Home State Health Plan Exchange |
$50.43
|
| Rate for Payer: Humana Medicare |
$66.36
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$66.36
|
| Rate for Payer: Provider Network of America Commercial |
$70.78
|
| Rate for Payer: UnitedHealthcare Commercial |
$58.40
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$88.48
|
|
|
sodium bicarbonate 4.2 % solution 5 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00409555512
|
|
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
|
|
|
sodium bicarbonate 4.2 % solution 5 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00409555512
|
|
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
|
|
|
sodium bicarbonate 650 mg tablet 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 77333082725
|
|
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
|
|
|
sodium bicarbonate 650 mg tablet 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 77333082725
|
|
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
|
|
|
sodium bicarbonate 8.4 % (1 mEq/mL) syringe 50 mL Syringe
|
Facility
|
OP
|
$86.56
|
|
|
Service Code
|
NDC 76329335201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.34 |
| Max. Negotiated Rate |
$86.56 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$61.02
|
| Rate for Payer: Aetna Workers' Compensation |
$61.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$59.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$59.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$68.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$68.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$68.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$66.65
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$68.21
|
| Rate for Payer: Cash Price |
$86.56
|
| Rate for Payer: Cigna Commercial |
$52.97
|
| Rate for Payer: Cigna Medicare Advantage |
$49.34
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$54.53
|
| Rate for Payer: Home State Health Plan Exchange |
$49.34
|
| Rate for Payer: Humana Medicare |
$64.92
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$64.92
|
| Rate for Payer: Provider Network of America Commercial |
$69.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$57.13
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$86.56
|
|
|
sodium bicarbonate 8.4 % (1 mEq/mL) syringe 50 mL Syringe
|
Facility
|
IP
|
$86.56
|
|
|
Service Code
|
NDC 76329335201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.92 |
| 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 |
$86.56
|
| Rate for Payer: Cash Price |
$86.56
|
| 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 |
$64.92
|
| Rate for Payer: Provider Network of America Commercial |
$69.25
|
|
|
sodium bicarbonate 8.4 % (1 mEq/mL) syringe 50 mL Vial
|
Facility
|
OP
|
$99.36
|
|
|
Service Code
|
NDC 63323008950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.64 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$70.05
|
| Rate for Payer: Aetna Workers' Compensation |
$70.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$68.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$68.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$78.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$78.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$78.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$76.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$78.30
|
| Rate for Payer: Cash Price |
$99.36
|
| Rate for Payer: Cigna Commercial |
$60.81
|
| Rate for Payer: Cigna Medicare Advantage |
$56.64
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$62.60
|
| Rate for Payer: Home State Health Plan Exchange |
$56.64
|
| Rate for Payer: Humana Medicare |
$74.52
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$74.52
|
| Rate for Payer: Provider Network of America Commercial |
$79.49
|
| Rate for Payer: UnitedHealthcare Commercial |
$65.58
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$99.36
|
|
|
sodium bicarbonate 8.4 % (1 mEq/mL) syringe 50 mL Vial
|
Facility
|
IP
|
$99.36
|
|
|
Service Code
|
NDC 63323008950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.52 |
| 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 |
$99.36
|
| Rate for Payer: Cash Price |
$99.36
|
| 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 |
$74.52
|
| Rate for Payer: Provider Network of America Commercial |
$79.49
|
|
|
sodium bicarbonate-citric acid-simethicone 2.21-1.53 gram/4 gram granules, effervescent packet 1 Each Packet
|
Facility
|
IP
|
$9.45
|
|
|
Service Code
|
NDC 10361079301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.09 |
| 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 |
$9.45
|
| Rate for Payer: Cash Price |
$9.45
|
| 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 |
$7.09
|
| Rate for Payer: Provider Network of America Commercial |
$7.56
|
|
|
sodium bicarbonate-citric acid-simethicone 2.21-1.53 gram/4 gram granules, effervescent packet 1 Each Packet
|
Facility
|
OP
|
$9.45
|
|
|
Service Code
|
NDC 10361079301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$9.45 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$6.66
|
| Rate for Payer: Aetna Workers' Compensation |
$6.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$6.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$6.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$7.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$7.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$7.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$7.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$7.45
|
| Rate for Payer: Cash Price |
$9.45
|
| Rate for Payer: Cigna Commercial |
$5.78
|
| Rate for Payer: Cigna Medicare Advantage |
$5.39
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$5.95
|
| Rate for Payer: Home State Health Plan Exchange |
$5.39
|
| Rate for Payer: Humana Medicare |
$7.09
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$7.09
|
| Rate for Payer: Provider Network of America Commercial |
$7.56
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.24
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$9.45
|
|
|
sodium chloride 0.45 % parenteral solution 1,000 mL Bag
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
NDC 00990798509
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$48.75 |
| 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 |
$65.00
|
| Rate for Payer: Cash Price |
$65.00
|
| 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 |
$48.75
|
| Rate for Payer: Provider Network of America Commercial |
$52.00
|
|
