|
Sub Grft F/S/N/H/F/G/M/D <100sq Cm 1st 25 Sq Cm
|
Facility
|
IP
|
$3,994.64
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
Px07611527501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$3,994.64
|
| Rate for Payer: Cash Price |
$3,994.64
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,995.98
|
| Rate for Payer: Provider Network of America Commercial |
$3,195.71
|
|
|
Sub Grft F/S/N/H/F/G/M/D <100sq Cm 1st 25 Sq Cm
|
Facility
|
OP
|
$3,994.64
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
Px07611527501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$702.21 |
| Max. Negotiated Rate |
$3,994.64 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2,816.22
|
| Rate for Payer: Aetna Workers' Compensation |
$2,816.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$2,768.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$2,768.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$3,147.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3,147.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$3,147.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3,075.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$3,147.78
|
| Rate for Payer: Cash Price |
$3,994.64
|
| Rate for Payer: Cash Price |
$3,994.64
|
| Rate for Payer: Cigna Commercial |
$2,444.72
|
| Rate for Payer: Cigna Medicare Advantage |
$2,276.94
|
| Rate for Payer: Family Health Partners Medicaid |
$932.72
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2,516.62
|
| Rate for Payer: Healthy Blue Medicaid |
$1,007.34
|
| Rate for Payer: Home State Health Plan Exchange |
$2,276.94
|
| Rate for Payer: Home State Health Plan Medicaid |
$932.72
|
| Rate for Payer: Humana Medicare |
$2,995.98
|
| Rate for Payer: Mercy CarePlus Medicaid |
$932.72
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,995.98
|
| Rate for Payer: Provider Network of America Commercial |
$3,195.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,636.46
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$3,994.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$702.21
|
|
|
Sub Grft F/S/N/H/F/G/M/D<100sq Cm Ea Addl25sq Cm
|
Facility
|
IP
|
$3,465.00
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
Px07611527601
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$3,465.00
|
| Rate for Payer: Cash Price |
$3,465.00
|
| 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 |
$2,598.75
|
| Rate for Payer: Provider Network of America Commercial |
$2,772.00
|
|
|
Sub Grft F/S/N/H/F/G/M/D<100sq Cm Ea Addl25sq Cm
|
Facility
|
OP
|
$3,465.00
|
|
|
Service Code
|
CPT 15276
|
| Hospital Charge Code |
Px07611527601
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,975.05 |
| Max. Negotiated Rate |
$3,465.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2,442.82
|
| Rate for Payer: Aetna Workers' Compensation |
$2,442.82
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$2,401.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$2,401.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$2,730.42
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$2,730.42
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$2,730.42
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$2,668.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$2,730.42
|
| Rate for Payer: Cash Price |
$3,465.00
|
| Rate for Payer: Cigna Commercial |
$2,120.58
|
| Rate for Payer: Cigna Medicare Advantage |
$1,975.05
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2,182.95
|
| Rate for Payer: Home State Health Plan Exchange |
$1,975.05
|
| Rate for Payer: Humana Medicare |
$2,598.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2,598.75
|
| Rate for Payer: Provider Network of America Commercial |
$2,772.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,286.90
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$3,465.00
|
|
|
Subq Hospital Care per Day E/M Normal Newborn
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 99462
|
| Hospital Charge Code |
Px09839946201
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$75.00 |
| 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 |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| 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 |
$75.00
|
| Rate for Payer: Provider Network of America Commercial |
$80.00
|
|
|
Subq Hospital Care per Day E/M Normal Newborn
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 99462
|
| Hospital Charge Code |
Px09839946201
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$57.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$70.50
|
| Rate for Payer: Aetna Workers' Compensation |
$70.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$69.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$69.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$78.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$78.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$78.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$77.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$78.80
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$61.20
|
| Rate for Payer: Cigna Medicare Advantage |
$57.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$63.00
|
| Rate for Payer: Home State Health Plan Exchange |
$57.00
|
| Rate for Payer: Humana Medicare |
$75.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$75.00
|
| Rate for Payer: Provider Network of America Commercial |
$80.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$66.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$100.00
|
|
|
succinylcholine 20 mg/mL solution 10 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J0330
|
|
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
|
|
|
succinylcholine 20 mg/mL solution 10 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 31722098131
|
|
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
|
|
|
succinylcholine 20 mg/mL solution 10 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J0330
|
|
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
|
|
|
succinylcholine 20 mg/mL solution 10 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 31722098131
|
|
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
|
|
|
succinylcholine (PF) 200 mg/10 mL (20 mg/mL) syringe 10 mL Syringe
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
NDC 71449012615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.00 |
| 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 |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| 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 |
$63.00
|
| Rate for Payer: Provider Network of America Commercial |
$67.20
|
|
|
succinylcholine (PF) 200 mg/10 mL (20 mg/mL) syringe 10 mL Syringe
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
NDC 71449012615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.88 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$59.22
|
| Rate for Payer: Aetna Workers' Compensation |
$59.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$58.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$58.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$66.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$66.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$66.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$64.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$66.19
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$51.41
|
| Rate for Payer: Cigna Medicare Advantage |
$47.88
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$52.92
|
| Rate for Payer: Home State Health Plan Exchange |
$47.88
|
| Rate for Payer: Humana Medicare |
$63.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Provider Network of America Commercial |
$67.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$55.44
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$84.00
|
|
|
sucralfate 1 gram tablet 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 51079075301
|
|
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
|
|
|
sucralfate 1 gram tablet 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 51079075301
|
|
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
|
|
|
sugammadex 100 mg/mL solution 2 mL Vial
|
Facility
|
IP
|
$571.76
|
|
|
Service Code
|
NDC 00006542302
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$428.82 |
| 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 |
$571.76
|
| Rate for Payer: Cash Price |
$571.76
|
| 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 |
$428.82
|
| Rate for Payer: Provider Network of America Commercial |
$457.41
|
|
|
sugammadex 100 mg/mL solution 2 mL Vial
|
Facility
|
OP
|
$571.76
|
|
|
Service Code
|
NDC 00006542302
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$325.90 |
| Max. Negotiated Rate |
$571.76 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$403.09
|
| Rate for Payer: Aetna Workers' Compensation |
$403.09
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$396.23
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$396.23
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$450.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$450.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$450.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$440.26
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$450.55
|
| Rate for Payer: Cash Price |
$571.76
|
| Rate for Payer: Cigna Commercial |
$349.92
|
| Rate for Payer: Cigna Medicare Advantage |
$325.90
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$360.21
|
| Rate for Payer: Home State Health Plan Exchange |
$325.90
|
| Rate for Payer: Humana Medicare |
$428.82
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$428.82
|
| Rate for Payer: Provider Network of America Commercial |
$457.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$377.36
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$571.76
|
|
|
sugammadex 100 mg/mL solution 2 mL Vial
|
Facility
|
IP
|
$571.76
|
|
|
Service Code
|
HCPCS J3490
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$428.82 |
| 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 |
$571.76
|
| Rate for Payer: Cash Price |
$571.76
|
| 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 |
$428.82
|
| Rate for Payer: Provider Network of America Commercial |
$457.41
|
|
|
sugammadex 100 mg/mL solution 2 mL Vial
|
Facility
|
OP
|
$571.76
|
|
|
Service Code
|
HCPCS J3490
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$325.90 |
| Max. Negotiated Rate |
$571.76 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$403.09
|
| Rate for Payer: Aetna Workers' Compensation |
$403.09
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$396.23
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$396.23
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$450.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$450.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$450.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$440.26
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$450.55
|
| Rate for Payer: Cash Price |
$571.76
|
| Rate for Payer: Cigna Commercial |
$349.92
|
| Rate for Payer: Cigna Medicare Advantage |
$325.90
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$360.21
|
| Rate for Payer: Home State Health Plan Exchange |
$325.90
|
| Rate for Payer: Humana Medicare |
$428.82
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$428.82
|
| Rate for Payer: Provider Network of America Commercial |
$457.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$377.36
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$571.76
|
|
|
sulfacetamide 10 % drops 15 mL DROP BTL
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
NDC 24208067004
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.25 |
| 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 |
$195.00
|
| Rate for Payer: Cash Price |
$195.00
|
| 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 |
$146.25
|
| Rate for Payer: Provider Network of America Commercial |
$156.00
|
|
|
sulfacetamide 10 % drops 15 mL DROP BTL
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
NDC 24208067004
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.15 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$137.47
|
| Rate for Payer: Aetna Workers' Compensation |
$137.47
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$135.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$135.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$153.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$153.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$153.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$150.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$153.66
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$119.34
|
| Rate for Payer: Cigna Medicare Advantage |
$111.15
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$122.85
|
| Rate for Payer: Home State Health Plan Exchange |
$111.15
|
| Rate for Payer: Humana Medicare |
$146.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$146.25
|
| Rate for Payer: Provider Network of America Commercial |
$156.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$128.70
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$195.00
|
|
|
sulfamethoxazole-trimethoprim 200-40 mg/5 mL suspension 473 mL Bottle
|
Facility
|
OP
|
$172.27
|
|
|
Service Code
|
NDC 70954025810
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.19 |
| Max. Negotiated Rate |
$172.27 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$121.45
|
| Rate for Payer: Aetna Workers' Compensation |
$121.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$119.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$119.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$135.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$135.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$135.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$132.65
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$135.75
|
| Rate for Payer: Cash Price |
$172.27
|
| Rate for Payer: Cigna Commercial |
$105.43
|
| Rate for Payer: Cigna Medicare Advantage |
$98.19
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$108.53
|
| Rate for Payer: Home State Health Plan Exchange |
$98.19
|
| Rate for Payer: Humana Medicare |
$129.20
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$129.20
|
| Rate for Payer: Provider Network of America Commercial |
$137.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$113.70
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$172.27
|
|
|
sulfamethoxazole-trimethoprim 200-40 mg/5 mL suspension 473 mL Bottle
|
Facility
|
IP
|
$172.27
|
|
|
Service Code
|
NDC 70954025810
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.20 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$129.20
|
| 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 |
$172.27
|
| Rate for Payer: Cash Price |
$172.27
|
| 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: Provider Network of America Commercial |
$137.82
|
|
|
sulfamethoxazole-trimethoprim 400-80 mg/5 mL solution 10 mL Vial
|
Facility
|
IP
|
$50.16
|
|
|
Service Code
|
NDC 00703951403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.62 |
| 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 |
$50.16
|
| Rate for Payer: Cash Price |
$50.16
|
| 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 |
$37.62
|
| Rate for Payer: Provider Network of America Commercial |
$40.13
|
|
|
sulfamethoxazole-trimethoprim 400-80 mg/5 mL solution 10 mL Vial
|
Facility
|
OP
|
$50.16
|
|
|
Service Code
|
HCPCS J2865
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.59 |
| Max. Negotiated Rate |
$50.16 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$35.36
|
| Rate for Payer: Aetna Workers' Compensation |
$35.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$34.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$34.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$39.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$39.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$39.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$38.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$39.53
|
| Rate for Payer: Cash Price |
$50.16
|
| Rate for Payer: Cigna Commercial |
$30.70
|
| Rate for Payer: Cigna Medicare Advantage |
$28.59
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$31.60
|
| Rate for Payer: Home State Health Plan Exchange |
$28.59
|
| Rate for Payer: Humana Medicare |
$37.62
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$37.62
|
| Rate for Payer: Provider Network of America Commercial |
$40.13
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.11
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$50.16
|
|
|
sulfamethoxazole-trimethoprim 400-80 mg/5 mL solution 10 mL Vial
|
Facility
|
OP
|
$50.16
|
|
|
Service Code
|
NDC 00703951403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.59 |
| Max. Negotiated Rate |
$50.16 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$35.36
|
| Rate for Payer: Aetna Workers' Compensation |
$35.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$34.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$34.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$39.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$39.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$39.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$38.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$39.53
|
| Rate for Payer: Cash Price |
$50.16
|
| Rate for Payer: Cigna Commercial |
$30.70
|
| Rate for Payer: Cigna Medicare Advantage |
$28.59
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$31.60
|
| Rate for Payer: Home State Health Plan Exchange |
$28.59
|
| Rate for Payer: Humana Medicare |
$37.62
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$37.62
|
| Rate for Payer: Provider Network of America Commercial |
$40.13
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.11
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$50.16
|
|
