|
sulfamethoxazole-trimethoprim 400-80 mg/5 mL solution 10 mL Vial
|
Facility
|
IP
|
$50.16
|
|
|
Service Code
|
HCPCS J2865
|
|
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 tablet 100 Each Bottle
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 65862041901
|
|
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
|
|
|
sulfamethoxazole-trimethoprim 400-80 mg tablet 100 Each Bottle
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 65862041901
|
|
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
|
|
|
sulfamethoxazole-trimethoprim 800-160 mg tablet 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687061411
|
|
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
|
|
|
sulfamethoxazole-trimethoprim 800-160 mg tablet 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687061411
|
|
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
|
|
|
sulfaSALAzine 500 mg tablet 100 Each Bottle
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 59762500005
|
|
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
|
|
|
sulfaSALAzine 500 mg tablet 100 Each Bottle
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 59762500005
|
|
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
|
|
|
sulfur hexafluoride microsphr 25 mg suspension for reconstitution 1 Each Vial
|
Facility
|
IP
|
$682.08
|
|
|
Service Code
|
HCPCS Q9950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$511.56 |
| 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 |
$682.08
|
| Rate for Payer: Cash Price |
$568.40
|
| Rate for Payer: Cash Price |
$568.40
|
| Rate for Payer: Cash Price |
$682.08
|
| 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 |
$426.30
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$511.56
|
| Rate for Payer: Provider Network of America Commercial |
$454.72
|
| Rate for Payer: Provider Network of America Commercial |
$545.66
|
|
|
sulfur hexafluoride microsphr 25 mg suspension for reconstitution 1 Each Vial
|
Facility
|
OP
|
$682.08
|
|
|
Service Code
|
NDC 00270709916
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$388.79 |
| Max. Negotiated Rate |
$682.08 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$480.87
|
| Rate for Payer: Aetna Workers' Compensation |
$480.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$472.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$472.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$537.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$537.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$537.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$525.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$537.48
|
| Rate for Payer: Cash Price |
$682.08
|
| Rate for Payer: Cigna Commercial |
$417.43
|
| Rate for Payer: Cigna Medicare Advantage |
$388.79
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$429.71
|
| Rate for Payer: Home State Health Plan Exchange |
$388.79
|
| Rate for Payer: Humana Medicare |
$511.56
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$511.56
|
| Rate for Payer: Provider Network of America Commercial |
$545.66
|
| Rate for Payer: UnitedHealthcare Commercial |
$450.17
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$682.08
|
|
|
sulfur hexafluoride microsphr 25 mg suspension for reconstitution 1 Each Vial
|
Facility
|
IP
|
$682.08
|
|
|
Service Code
|
NDC 00270709916
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$511.56 |
| 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 |
$682.08
|
| Rate for Payer: Cash Price |
$682.08
|
| 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 |
$511.56
|
| Rate for Payer: Provider Network of America Commercial |
$545.66
|
|
|
sulfur hexafluoride microsphr 25 mg suspension for reconstitution 1 Each Vial
|
Facility
|
OP
|
$568.40
|
|
|
Service Code
|
HCPCS Q9950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$323.99 |
| Max. Negotiated Rate |
$568.40 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$400.72
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$480.87
|
| Rate for Payer: Aetna Workers' Compensation |
$400.72
|
| Rate for Payer: Aetna Workers' Compensation |
$480.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$393.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$472.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$393.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$472.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$537.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$447.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$537.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$447.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$447.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$537.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$437.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$525.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$537.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$447.90
|
| Rate for Payer: Cash Price |
$682.08
|
| Rate for Payer: Cash Price |
$568.40
|
| Rate for Payer: Cigna Commercial |
$347.86
|
| Rate for Payer: Cigna Commercial |
$417.43
|
| Rate for Payer: Cigna Medicare Advantage |
$323.99
|
| Rate for Payer: Cigna Medicare Advantage |
$388.79
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$358.09
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$429.71
|
| Rate for Payer: Home State Health Plan Exchange |
$323.99
|
| Rate for Payer: Home State Health Plan Exchange |
$388.79
|
| Rate for Payer: Humana Medicare |
$426.30
|
| Rate for Payer: Humana Medicare |
$511.56
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$426.30
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$511.56
|
| Rate for Payer: Provider Network of America Commercial |
$454.72
|
| Rate for Payer: Provider Network of America Commercial |
$545.66
|
| Rate for Payer: UnitedHealthcare Commercial |
$375.14
|
| Rate for Payer: UnitedHealthcare Commercial |
$450.17
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$568.40
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$682.08
|
|
|
sulfur hexafluoride microsphr 25 mg suspension for reconstitution 1 Each Vial
|
Facility
|
IP
|
$568.40
|
|
|
Service Code
|
NDC 00270709973
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$426.30 |
| 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 |
$568.40
|
| Rate for Payer: Cash Price |
$568.40
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$426.30
|
| Rate for Payer: Provider Network of America Commercial |
$454.72
|
|
|
sulfur hexafluoride microsphr 25 mg suspension for reconstitution 1 Each Vial
|
Facility
|
OP
|
$568.40
|
|
|
Service Code
|
NDC 00270709973
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$323.99 |
| Max. Negotiated Rate |
$568.40 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$400.72
|
| Rate for Payer: Aetna Workers' Compensation |
$400.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$393.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$393.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$447.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$447.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$447.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$437.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$447.90
|
| Rate for Payer: Cash Price |
$568.40
|
| Rate for Payer: Cigna Commercial |
$347.86
|
| Rate for Payer: Cigna Medicare Advantage |
$323.99
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$358.09
|
| Rate for Payer: Home State Health Plan Exchange |
$323.99
|
| Rate for Payer: Humana Medicare |
$426.30
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$426.30
|
| Rate for Payer: Provider Network of America Commercial |
$454.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$375.14
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$568.40
|
|
|
SUMAtriptan 6 mg/0.5 mL solution 0.5 mL Vial
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
NDC 55150017301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.00 |
| 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 |
$44.00
|
| Rate for Payer: Cash Price |
$44.00
|
| 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 |
$33.00
|
| Rate for Payer: Provider Network of America Commercial |
$35.20
|
|
|
SUMAtriptan 6 mg/0.5 mL solution 0.5 mL Vial
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
NDC 55150017301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.08 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$31.02
|
| Rate for Payer: Aetna Workers' Compensation |
$31.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$30.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$30.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$34.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$34.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$34.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$33.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$34.67
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Cigna Commercial |
$26.93
|
| Rate for Payer: Cigna Medicare Advantage |
$25.08
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$27.72
|
| Rate for Payer: Home State Health Plan Exchange |
$25.08
|
| Rate for Payer: Humana Medicare |
$33.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Provider Network of America Commercial |
$35.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$29.04
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$44.00
|
|
|
SUMAtriptan 6 mg/0.5 mL solution 0.5 mL Vial
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
HCPCS J3030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.00 |
| 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 |
$44.00
|
| Rate for Payer: Cash Price |
$44.00
|
| 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 |
$33.00
|
| Rate for Payer: Provider Network of America Commercial |
$35.20
|
|
|
SUMAtriptan 6 mg/0.5 mL solution 0.5 mL Vial
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
HCPCS J3030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.08 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$31.02
|
| Rate for Payer: Aetna Workers' Compensation |
$31.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$30.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$30.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$34.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$34.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$34.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$33.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$34.67
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Cigna Commercial |
$26.93
|
| Rate for Payer: Cigna Medicare Advantage |
$25.08
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$27.72
|
| Rate for Payer: Home State Health Plan Exchange |
$25.08
|
| Rate for Payer: Humana Medicare |
$33.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$33.00
|
| Rate for Payer: Provider Network of America Commercial |
$35.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$29.04
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$44.00
|
|
|
SUMAtriptan succinate 50 mg tablet 9 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 65862014736
|
|
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
|
|
|
SUMAtriptan succinate 50 mg tablet 9 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 65862014736
|
|
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
|
|
|
Surgical Arthroscopy Shoulder Capsulorrhaphy
|
Facility
|
IP
|
$14,608.65
|
|
|
Service Code
|
CPT 29806
|
| Hospital Charge Code |
Px03602980601
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$11,686.92 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$14,608.65
|
| Rate for Payer: Cash Price |
$14,608.65
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$10,956.49
|
| Rate for Payer: Provider Network of America Commercial |
$11,686.92
|
|
|
Surgical Arthroscopy Shoulder Capsulorrhaphy
|
Facility
|
IP
|
$13,913.00
|
|
|
Service Code
|
CPT 29806
|
| Hospital Charge Code |
Px09832980601
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$11,130.40 |
| 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 |
$14,608.65
|
| Rate for Payer: Cash Price |
$13,913.00
|
| Rate for Payer: Cash Price |
$13,913.00
|
| Rate for Payer: Cash Price |
$14,608.65
|
| 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 |
$10,956.49
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$10,434.75
|
| Rate for Payer: Provider Network of America Commercial |
$11,130.40
|
| Rate for Payer: Provider Network of America Commercial |
$11,686.92
|
|
|
Surgical Arthroscopy Shoulder Capsulorrhaphy
|
Facility
|
OP
|
$14,608.65
|
|
|
Service Code
|
CPT 29806
|
| Hospital Charge Code |
Px03602980601
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,894.33 |
| Max. Negotiated Rate |
$14,608.65 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$10,123.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$10,123.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$11,511.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$11,511.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$11,511.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$11,248.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$11,511.62
|
| Rate for Payer: Cash Price |
$14,608.65
|
| Rate for Payer: Cash Price |
$14,608.65
|
| Rate for Payer: Cigna Commercial |
$9,685.53
|
| Rate for Payer: Cigna Medicare Advantage |
$8,326.93
|
| Rate for Payer: Family Health Partners Medicaid |
$9,157.55
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$9,203.45
|
| Rate for Payer: Healthy Blue Medicaid |
$9,890.16
|
| Rate for Payer: Home State Health Plan Exchange |
$8,326.93
|
| Rate for Payer: Home State Health Plan Medicaid |
$9,157.55
|
| Rate for Payer: Humana Medicare |
$10,956.49
|
| Rate for Payer: Mercy CarePlus Medicaid |
$9,157.55
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$10,956.49
|
| Rate for Payer: Provider Network of America Commercial |
$11,686.92
|
| Rate for Payer: UnitedHealthcare Commercial |
$9,641.71
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$14,608.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,894.33
|
|
|
Surgical Arthroscopy Shoulder Capsulorrhaphy
|
Facility
|
OP
|
$13,913.00
|
|
|
Service Code
|
CPT 29806
|
| Hospital Charge Code |
Px09832980601
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,894.33 |
| Max. Negotiated Rate |
$13,913.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$9,641.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$10,123.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$10,123.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$9,641.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$11,511.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$10,963.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$11,511.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$10,963.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$10,963.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$11,511.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$11,248.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$10,713.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$10,963.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$11,511.62
|
| Rate for Payer: Cash Price |
$13,913.00
|
| Rate for Payer: Cash Price |
$14,608.65
|
| Rate for Payer: Cash Price |
$14,608.65
|
| Rate for Payer: Cash Price |
$13,913.00
|
| Rate for Payer: Cigna Commercial |
$9,685.53
|
| Rate for Payer: Cigna Commercial |
$9,224.32
|
| Rate for Payer: Cigna Medicare Advantage |
$8,326.93
|
| Rate for Payer: Cigna Medicare Advantage |
$7,930.41
|
| Rate for Payer: Family Health Partners Medicaid |
$9,157.55
|
| Rate for Payer: Family Health Partners Medicaid |
$9,157.55
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$9,203.45
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$8,765.19
|
| Rate for Payer: Healthy Blue Medicaid |
$9,890.16
|
| Rate for Payer: Healthy Blue Medicaid |
$9,890.16
|
| Rate for Payer: Home State Health Plan Exchange |
$7,930.41
|
| Rate for Payer: Home State Health Plan Exchange |
$8,326.93
|
| Rate for Payer: Home State Health Plan Medicaid |
$9,157.55
|
| Rate for Payer: Home State Health Plan Medicaid |
$9,157.55
|
| Rate for Payer: Humana Medicare |
$10,956.49
|
| Rate for Payer: Humana Medicare |
$10,434.75
|
| Rate for Payer: Mercy CarePlus Medicaid |
$9,157.55
|
| Rate for Payer: Mercy CarePlus Medicaid |
$9,157.55
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$10,434.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$10,956.49
|
| Rate for Payer: Provider Network of America Commercial |
$11,686.92
|
| Rate for Payer: Provider Network of America Commercial |
$11,130.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$9,641.71
|
| Rate for Payer: UnitedHealthcare Commercial |
$9,182.58
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$14,608.65
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$13,913.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,894.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,894.33
|
|
|
Surgical Arthroscopy Shoulder Repair Slap Lesion
|
Facility
|
OP
|
$14,608.42
|
|
|
Service Code
|
CPT 29807
|
| Hospital Charge Code |
Px03602980701
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,894.33 |
| Max. Negotiated Rate |
$14,608.42 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$10,123.64
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$10,123.64
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$11,511.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$11,511.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$11,511.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$11,248.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$11,511.43
|
| Rate for Payer: Cash Price |
$14,608.42
|
| Rate for Payer: Cash Price |
$14,608.42
|
| Rate for Payer: Cigna Commercial |
$9,685.38
|
| Rate for Payer: Cigna Medicare Advantage |
$8,326.80
|
| Rate for Payer: Family Health Partners Medicaid |
$9,157.55
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$9,203.30
|
| Rate for Payer: Healthy Blue Medicaid |
$9,890.16
|
| Rate for Payer: Home State Health Plan Exchange |
$8,326.80
|
| Rate for Payer: Home State Health Plan Medicaid |
$9,157.55
|
| Rate for Payer: Humana Medicare |
$10,956.32
|
| Rate for Payer: Mercy CarePlus Medicaid |
$9,157.55
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$10,956.32
|
| Rate for Payer: Provider Network of America Commercial |
$11,686.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$9,641.56
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$14,608.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,894.33
|
|
|
Surgical Arthroscopy Shoulder Repair Slap Lesion
|
Facility
|
IP
|
$14,608.42
|
|
|
Service Code
|
CPT 29807
|
| Hospital Charge Code |
Px03602980701
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$11,686.74 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$14,608.42
|
| Rate for Payer: Cash Price |
$14,608.42
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$10,956.32
|
| Rate for Payer: Provider Network of America Commercial |
$11,686.74
|
|
