|
dexAMETHasone (PF) 10 mg/mL solution 1 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J1100
|
|
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
|
|
|
dexAMETHasone (PF) 10 mg/mL solution 1 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 55150030401
|
|
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
|
|
|
Dexamethasone Sodium Phos
|
Facility
|
IP
|
$26.25
|
|
|
Service Code
|
CPT J1100
|
| Hospital Charge Code |
Px0636J110001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.69 |
| 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 |
$26.25
|
| Rate for Payer: Cash Price |
$26.25
|
| 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 |
$19.69
|
| Rate for Payer: Provider Network of America Commercial |
$21.00
|
|
|
Dexamethasone Sodium Phos
|
Facility
|
OP
|
$26.25
|
|
|
Service Code
|
CPT J1100
|
| Hospital Charge Code |
Px0636J110001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$18.51
|
| Rate for Payer: Aetna Workers' Compensation |
$18.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$18.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$18.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$20.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$20.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$20.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$20.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$20.68
|
| Rate for Payer: Cash Price |
$26.25
|
| Rate for Payer: Cigna Commercial |
$16.07
|
| Rate for Payer: Cigna Medicare Advantage |
$14.96
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$16.54
|
| Rate for Payer: Home State Health Plan Exchange |
$14.96
|
| Rate for Payer: Humana Medicare |
$19.69
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$19.69
|
| Rate for Payer: Provider Network of America Commercial |
$21.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.32
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$26.25
|
|
|
dexAMETHasone sodium phosphate 0.1 % drops 5 mL DROP BTL
|
Facility
|
OP
|
$215.60
|
|
|
Service Code
|
NDC 24208072002
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.89 |
| Max. Negotiated Rate |
$215.60 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$152.00
|
| Rate for Payer: Aetna Workers' Compensation |
$152.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$149.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$149.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$169.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$169.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$169.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$166.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$169.89
|
| Rate for Payer: Cash Price |
$215.60
|
| Rate for Payer: Cigna Commercial |
$131.95
|
| Rate for Payer: Cigna Medicare Advantage |
$122.89
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$135.83
|
| Rate for Payer: Home State Health Plan Exchange |
$122.89
|
| Rate for Payer: Humana Medicare |
$161.70
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$161.70
|
| Rate for Payer: Provider Network of America Commercial |
$172.48
|
| Rate for Payer: UnitedHealthcare Commercial |
$142.30
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$215.60
|
|
|
dexAMETHasone sodium phosphate 0.1 % drops 5 mL DROP BTL
|
Facility
|
IP
|
$215.60
|
|
|
Service Code
|
NDC 24208072002
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.70 |
| 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 |
$215.60
|
| Rate for Payer: Cash Price |
$215.60
|
| 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 |
$161.70
|
| Rate for Payer: Provider Network of America Commercial |
$172.48
|
|
|
dexmedeTOMIDine 100 mcg/mL solution 4 mL Vial
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
NDC 44567060004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$213.75 |
| 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 |
$285.00
|
| Rate for Payer: Cash Price |
$285.00
|
| 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 |
$213.75
|
| Rate for Payer: Provider Network of America Commercial |
$228.00
|
|
|
dexmedeTOMIDine 100 mcg/mL solution 4 mL Vial
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS J3490
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.20 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$42.30
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$200.93
|
| Rate for Payer: Aetna Workers' Compensation |
$200.93
|
| Rate for Payer: Aetna Workers' Compensation |
$42.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$197.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$41.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$197.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$41.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$47.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$224.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$224.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$47.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$47.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$224.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$46.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$219.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$224.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$47.28
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$174.42
|
| Rate for Payer: Cigna Commercial |
$36.72
|
| Rate for Payer: Cigna Medicare Advantage |
$34.20
|
| Rate for Payer: Cigna Medicare Advantage |
$162.45
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$37.80
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$179.55
|
| Rate for Payer: Home State Health Plan Exchange |
$162.45
|
| Rate for Payer: Home State Health Plan Exchange |
$34.20
|
| Rate for Payer: Humana Medicare |
$45.00
|
| Rate for Payer: Humana Medicare |
$213.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$213.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$45.00
|
| Rate for Payer: Provider Network of America Commercial |
$48.00
|
| Rate for Payer: Provider Network of America Commercial |
$228.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$188.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$39.60
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$285.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$60.00
|
|
|
dexmedeTOMIDine 100 mcg/mL solution 4 mL Vial
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS J3490
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.00 |
| 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 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 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: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$45.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$213.75
|
| Rate for Payer: Provider Network of America Commercial |
$48.00
|
| Rate for Payer: Provider Network of America Commercial |
$228.00
|
|
|
dexmedeTOMIDine 100 mcg/mL solution 4 mL Vial
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
NDC 44567060004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$162.45 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$200.93
|
| Rate for Payer: Aetna Workers' Compensation |
$200.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$197.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$197.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$224.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$224.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$224.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$219.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$224.58
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cigna Commercial |
$174.42
|
| Rate for Payer: Cigna Medicare Advantage |
$162.45
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$179.55
|
| Rate for Payer: Home State Health Plan Exchange |
$162.45
|
| Rate for Payer: Humana Medicare |
$213.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$213.75
|
| Rate for Payer: Provider Network of America Commercial |
$228.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$188.10
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$285.00
|
|
|
dexmedeTOMIDine 100 mcg/mL solution 4 mL Vial
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 70069075801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.20 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$42.30
|
| Rate for Payer: Aetna Workers' Compensation |
$42.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$41.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$41.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$47.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$47.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$47.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$46.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$47.28
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$36.72
|
| Rate for Payer: Cigna Medicare Advantage |
$34.20
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$37.80
|
| Rate for Payer: Home State Health Plan Exchange |
$34.20
|
| Rate for Payer: Humana Medicare |
$45.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$45.00
|
| Rate for Payer: Provider Network of America Commercial |
$48.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$39.60
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$60.00
|
|
|
dexmedeTOMIDine 100 mcg/mL solution 4 mL Vial
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 70069075801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.00 |
| 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 |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| 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 |
$45.00
|
| Rate for Payer: Provider Network of America Commercial |
$48.00
|
|
|
Dextran 40 infusion
|
Facility
|
OP
|
$163.83
|
|
|
Service Code
|
HCPCS J7100
|
| Hospital Charge Code |
Px0636J710001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.38 |
| Max. Negotiated Rate |
$163.83 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$115.50
|
| Rate for Payer: Aetna Workers' Compensation |
$115.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$113.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$113.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$129.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$129.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$129.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$126.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$129.10
|
| Rate for Payer: Cash Price |
$163.83
|
| Rate for Payer: Cigna Commercial |
$100.26
|
| Rate for Payer: Cigna Medicare Advantage |
$93.38
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$103.21
|
| Rate for Payer: Home State Health Plan Exchange |
$93.38
|
| Rate for Payer: Humana Medicare |
$122.87
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$122.87
|
| Rate for Payer: Provider Network of America Commercial |
$131.06
|
| Rate for Payer: UnitedHealthcare Commercial |
$108.13
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$163.83
|
|
|
Dextran 40 infusion
|
Facility
|
IP
|
$163.83
|
|
|
Service Code
|
HCPCS J7100
|
| Hospital Charge Code |
Px0636J710001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.87 |
| 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 |
$163.83
|
| Rate for Payer: Cash Price |
$163.83
|
| 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 |
$122.87
|
| Rate for Payer: Provider Network of America Commercial |
$131.06
|
|
|
dextromethorphan-guaifenesin 10-100 mg/5 mL syrup 10 mL Cup
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 69339015001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.75 |
| 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 |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| 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 |
$33.75
|
| Rate for Payer: Provider Network of America Commercial |
$36.00
|
|
|
dextromethorphan-guaifenesin 10-100 mg/5 mL syrup 10 mL Cup
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 69339015001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.65 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$31.73
|
| Rate for Payer: Aetna Workers' Compensation |
$31.73
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$31.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$31.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$35.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$35.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$35.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$34.65
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$35.46
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$27.54
|
| Rate for Payer: Cigna Medicare Advantage |
$25.65
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$28.35
|
| Rate for Payer: Home State Health Plan Exchange |
$25.65
|
| Rate for Payer: Humana Medicare |
$33.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$33.75
|
| Rate for Payer: Provider Network of America Commercial |
$36.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$29.70
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$45.00
|
|
|
dextromethorphan-guaifenesin 30-600 mg tablet extended release 12 hr 40 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 63824005634
|
|
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
|
|
|
dextromethorphan-guaifenesin 30-600 mg tablet extended release 12 hr 40 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 63824005634
|
|
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
|
|
|
dextromethorphan-guaifenesin 30-600 mg tablet extended release 12 hr 40 Each Box
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 63824005640
|
|
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
|
|
|
dextromethorphan-guaifenesin 30-600 mg tablet extended release 12 hr 40 Each Box
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 63824005640
|
|
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
|
|
|
dextrose 10 % parenteral solution 250 mL Flex Cont
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
NDC 00990793002
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$37.05 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$45.83
|
| Rate for Payer: Aetna Workers' Compensation |
$45.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$45.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$45.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$51.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$51.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$51.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$50.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$51.22
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$39.78
|
| Rate for Payer: Cigna Medicare Advantage |
$37.05
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$40.95
|
| Rate for Payer: Home State Health Plan Exchange |
$37.05
|
| Rate for Payer: Humana Medicare |
$48.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$48.75
|
| Rate for Payer: Provider Network of America Commercial |
$52.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$42.90
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$65.00
|
|
|
dextrose 10 % parenteral solution 250 mL Flex Cont
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
NDC 00990793002
|
|
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
|
|
|
dextrose 25 % syringe 10 mL Syringe
|
Facility
|
OP
|
$90.58
|
|
|
Service Code
|
NDC 00409177540
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$51.63 |
| Max. Negotiated Rate |
$90.58 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$63.86
|
| Rate for Payer: Aetna Workers' Compensation |
$63.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$62.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$62.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$71.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$71.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$71.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$69.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$71.38
|
| Rate for Payer: Cash Price |
$90.58
|
| Rate for Payer: Cigna Commercial |
$55.43
|
| Rate for Payer: Cigna Medicare Advantage |
$51.63
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$57.07
|
| Rate for Payer: Home State Health Plan Exchange |
$51.63
|
| Rate for Payer: Humana Medicare |
$67.94
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$67.94
|
| Rate for Payer: Provider Network of America Commercial |
$72.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$59.78
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$90.58
|
|
|
dextrose 25 % syringe 10 mL Syringe
|
Facility
|
IP
|
$90.58
|
|
|
Service Code
|
NDC 00409177540
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$67.94 |
| 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 |
$90.58
|
| Rate for Payer: Cash Price |
$90.58
|
| 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 |
$67.94
|
| Rate for Payer: Provider Network of America Commercial |
$72.46
|
|
|
dextrose 50 % syringe 50 mL Syringe
|
Facility
|
IP
|
$88.96
|
|
|
Service Code
|
HCPCS A4216
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$66.72 |
| 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 |
$88.96
|
| Rate for Payer: Cash Price |
$88.96
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$66.72
|
| Rate for Payer: Provider Network of America Commercial |
$71.17
|
|
