|
sodium chloride (PF) 0.9 % solution 20 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 63323018603
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: UnitedHealthcare Commercial |
$23.10
|
| 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 Individual Exchange |
$35.00
|
|
|
sodium chloride (PF) 0.9 % solution 20 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00409488820
|
|
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 chloride (PF) 0.9 % solution 20 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00409488820
|
|
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 chloride (PF) 0.9 % solution 20 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 63323018603
|
|
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 chloride (PF) syringe 10 mL Syringe
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 08290306546
|
|
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 chloride (PF) syringe 10 mL Syringe
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 08290306500
|
|
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 chloride (PF) syringe 10 mL Syringe
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 08290306500
|
|
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 chloride (PF) syringe 10 mL Syringe
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 08290306546
|
|
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 citrate-citric acid 500-334 mg/5 mL solution 30 mL Cup
|
Facility
|
IP
|
$10.14
|
|
|
Service Code
|
NDC 00121119030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.61 |
| 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 |
$10.14
|
| Rate for Payer: Cash Price |
$10.14
|
| 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 |
$7.61
|
| Rate for Payer: Provider Network of America Commercial |
$8.11
|
|
|
sodium citrate-citric acid 500-334 mg/5 mL solution 30 mL Cup
|
Facility
|
OP
|
$10.14
|
|
|
Service Code
|
NDC 00121119030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$10.14 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$7.15
|
| Rate for Payer: Aetna Workers' Compensation |
$7.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$7.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$7.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$7.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$7.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$7.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$7.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$7.99
|
| Rate for Payer: Cash Price |
$10.14
|
| Rate for Payer: Cigna Commercial |
$6.21
|
| Rate for Payer: Cigna Medicare Advantage |
$5.78
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$6.39
|
| Rate for Payer: Home State Health Plan Exchange |
$5.78
|
| Rate for Payer: Humana Medicare |
$7.61
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$7.61
|
| Rate for Payer: Provider Network of America Commercial |
$8.11
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.69
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$10.14
|
|
|
sodium hyaluronate 60 mg/3 mL syringe 3 mL Syringe
|
Facility
|
IP
|
$4,460.00
|
|
|
Service Code
|
HCPCS J7318
|
|
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 |
$4,460.00
|
| Rate for Payer: Cash Price |
$4,460.00
|
| 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 |
$3,345.00
|
| Rate for Payer: Provider Network of America Commercial |
$3,568.00
|
|
|
sodium hyaluronate 60 mg/3 mL syringe 3 mL Syringe
|
Facility
|
OP
|
$4,460.00
|
|
|
Service Code
|
HCPCS J7318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,542.20 |
| Max. Negotiated Rate |
$4,460.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$3,144.30
|
| Rate for Payer: Aetna Workers' Compensation |
$3,144.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$3,090.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$3,090.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$3,514.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3,514.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$3,514.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3,434.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$3,514.48
|
| Rate for Payer: Cash Price |
$4,460.00
|
| Rate for Payer: Cigna Commercial |
$2,729.52
|
| Rate for Payer: Cigna Medicare Advantage |
$2,542.20
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2,809.80
|
| Rate for Payer: Home State Health Plan Exchange |
$2,542.20
|
| Rate for Payer: Humana Medicare |
$3,345.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3,345.00
|
| Rate for Payer: Provider Network of America Commercial |
$3,568.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,943.60
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$4,460.00
|
|
|
sodium hyaluronate 60 mg/3 mL syringe 3 mL Syringe
|
Facility
|
IP
|
$4,460.00
|
|
|
Service Code
|
NDC 16986002080
|
|
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 |
$4,460.00
|
| Rate for Payer: Cash Price |
$4,460.00
|
| 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 |
$3,345.00
|
| Rate for Payer: Provider Network of America Commercial |
$3,568.00
|
|
|
sodium hyaluronate 60 mg/3 mL syringe 3 mL Syringe
|
Facility
|
OP
|
$4,460.00
|
|
|
Service Code
|
NDC 16986002080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,542.20 |
| Max. Negotiated Rate |
$4,460.00 |
| Rate for Payer: UnitedHealthcare Commercial |
$2,943.60
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$3,144.30
|
| Rate for Payer: Aetna Workers' Compensation |
$3,144.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$3,090.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$3,090.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$3,514.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3,514.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$3,514.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3,434.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$3,514.48
|
| Rate for Payer: Cash Price |
$4,460.00
|
| Rate for Payer: Cigna Commercial |
$2,729.52
|
| Rate for Payer: Cigna Medicare Advantage |
$2,542.20
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2,809.80
|
| Rate for Payer: Home State Health Plan Exchange |
$2,542.20
|
| Rate for Payer: Humana Medicare |
$3,345.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3,345.00
|
| Rate for Payer: Provider Network of America Commercial |
$3,568.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$4,460.00
|
|
|
sodium hyaluronate 60 mg/3 mL syringe 3 mL Syringe
|
Facility
|
OP
|
$4,460.00
|
|
|
Service Code
|
NDC 89130202001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,542.20 |
| Max. Negotiated Rate |
$4,460.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$3,144.30
|
| Rate for Payer: Aetna Workers' Compensation |
$3,144.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$3,090.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$3,090.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$3,514.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3,514.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$3,514.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3,434.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$3,514.48
|
| Rate for Payer: Cash Price |
$4,460.00
|
| Rate for Payer: Cigna Commercial |
$2,729.52
|
| Rate for Payer: Cigna Medicare Advantage |
$2,542.20
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2,809.80
|
| Rate for Payer: Home State Health Plan Exchange |
$2,542.20
|
| Rate for Payer: Humana Medicare |
$3,345.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3,345.00
|
| Rate for Payer: Provider Network of America Commercial |
$3,568.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,943.60
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$4,460.00
|
|
|
sodium hyaluronate 60 mg/3 mL syringe 3 mL Syringe
|
Facility
|
IP
|
$4,460.00
|
|
|
Service Code
|
NDC 89130202001
|
|
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 |
$4,460.00
|
| Rate for Payer: Cash Price |
$4,460.00
|
| 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 |
$3,345.00
|
| Rate for Payer: Provider Network of America Commercial |
$3,568.00
|
|
|
sodium hyaluronate (viscosup) 10 mg/mL syringe 2 mL Syringe
|
Facility
|
IP
|
$760.00
|
|
|
Service Code
|
HCPCS J7321
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$570.00 |
| 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 |
$760.00
|
| Rate for Payer: Cash Price |
$760.00
|
| 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 |
$570.00
|
| Rate for Payer: Provider Network of America Commercial |
$608.00
|
|
|
sodium hyaluronate (viscosup) 10 mg/mL syringe 2 mL Syringe
|
Facility
|
OP
|
$760.00
|
|
|
Service Code
|
HCPCS J7321
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$433.20 |
| Max. Negotiated Rate |
$760.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$535.80
|
| Rate for Payer: Aetna Workers' Compensation |
$535.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$526.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$526.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$598.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$598.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$598.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$585.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$598.88
|
| Rate for Payer: Cash Price |
$760.00
|
| Rate for Payer: Cigna Commercial |
$465.12
|
| Rate for Payer: Cigna Medicare Advantage |
$433.20
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$478.80
|
| Rate for Payer: Home State Health Plan Exchange |
$433.20
|
| Rate for Payer: Humana Medicare |
$570.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$570.00
|
| Rate for Payer: Provider Network of America Commercial |
$608.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$501.60
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$760.00
|
|
|
sodium hyaluronate (viscosup) 10 mg/mL syringe 2 mL Syringe
|
Facility
|
OP
|
$760.00
|
|
|
Service Code
|
NDC 89122072420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$433.20 |
| Max. Negotiated Rate |
$760.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$535.80
|
| Rate for Payer: Aetna Workers' Compensation |
$535.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$526.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$526.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$598.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$598.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$598.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$585.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$598.88
|
| Rate for Payer: Cash Price |
$760.00
|
| Rate for Payer: Cigna Commercial |
$465.12
|
| Rate for Payer: Cigna Medicare Advantage |
$433.20
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$478.80
|
| Rate for Payer: Home State Health Plan Exchange |
$433.20
|
| Rate for Payer: Humana Medicare |
$570.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$570.00
|
| Rate for Payer: Provider Network of America Commercial |
$608.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$501.60
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$760.00
|
|
|
sodium hyaluronate (viscosup) 10 mg/mL syringe 2 mL Syringe
|
Facility
|
IP
|
$760.00
|
|
|
Service Code
|
NDC 89122072420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$570.00 |
| 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 |
$760.00
|
| Rate for Payer: Cash Price |
$760.00
|
| 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 |
$570.00
|
| Rate for Payer: Provider Network of America Commercial |
$608.00
|
|
|
sodium hyaluronate (viscosup) 16.8 mg/2 mL syringe 2 mL Syringe
|
Facility
|
IP
|
$1,552.00
|
|
|
Service Code
|
HCPCS J7328
|
|
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 |
$1,552.00
|
| Rate for Payer: Cash Price |
$1,552.00
|
| 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 |
$1,164.00
|
| Rate for Payer: Provider Network of America Commercial |
$1,241.60
|
|
|
sodium hyaluronate (viscosup) 16.8 mg/2 mL syringe 2 mL Syringe
|
Facility
|
OP
|
$1,552.00
|
|
|
Service Code
|
HCPCS J7328
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$884.64 |
| Max. Negotiated Rate |
$1,552.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,094.16
|
| Rate for Payer: Aetna Workers' Compensation |
$1,094.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,075.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,075.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,222.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,222.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,222.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$1,195.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,222.98
|
| Rate for Payer: Cash Price |
$1,552.00
|
| Rate for Payer: Cigna Commercial |
$949.82
|
| Rate for Payer: Cigna Medicare Advantage |
$884.64
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$977.76
|
| Rate for Payer: Home State Health Plan Exchange |
$884.64
|
| Rate for Payer: Humana Medicare |
$1,164.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,164.00
|
| Rate for Payer: Provider Network of America Commercial |
$1,241.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,024.32
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,552.00
|
|
|
sodium hyaluronate (viscosup) 16.8 mg/2 mL syringe 2 mL Syringe
|
Facility
|
OP
|
$1,552.00
|
|
|
Service Code
|
NDC 89130311101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$884.64 |
| Max. Negotiated Rate |
$1,552.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,094.16
|
| Rate for Payer: Aetna Workers' Compensation |
$1,094.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,075.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,075.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,222.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,222.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,222.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$1,195.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,222.98
|
| Rate for Payer: Cash Price |
$1,552.00
|
| Rate for Payer: Cigna Commercial |
$949.82
|
| Rate for Payer: Cigna Medicare Advantage |
$884.64
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$977.76
|
| Rate for Payer: Home State Health Plan Exchange |
$884.64
|
| Rate for Payer: Humana Medicare |
$1,164.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,164.00
|
| Rate for Payer: Provider Network of America Commercial |
$1,241.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,024.32
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,552.00
|
|
|
sodium hyaluronate (viscosup) 16.8 mg/2 mL syringe 2 mL Syringe
|
Facility
|
IP
|
$1,552.00
|
|
|
Service Code
|
NDC 89130311101
|
|
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 |
$1,552.00
|
| Rate for Payer: Cash Price |
$1,552.00
|
| 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 |
$1,164.00
|
| Rate for Payer: Provider Network of America Commercial |
$1,241.60
|
|
|
sodium hyaluronate (viscosup) 30 mg/2 mL syringe 2 mL Syringe
|
Facility
|
OP
|
$1,912.00
|
|
|
Service Code
|
HCPCS J7324
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,089.84 |
| Max. Negotiated Rate |
$1,912.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,347.96
|
| Rate for Payer: Aetna Workers' Compensation |
$1,347.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,325.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,325.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,506.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,506.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,506.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$1,472.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,506.66
|
| Rate for Payer: Cash Price |
$1,912.00
|
| Rate for Payer: Cigna Commercial |
$1,170.14
|
| Rate for Payer: Cigna Medicare Advantage |
$1,089.84
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,204.56
|
| Rate for Payer: Home State Health Plan Exchange |
$1,089.84
|
| Rate for Payer: Humana Medicare |
$1,434.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,434.00
|
| Rate for Payer: Provider Network of America Commercial |
$1,529.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,261.92
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,912.00
|
|
