|
Surg Path,Level IV - Lab Surg Path,Level IV
|
Facility
|
OP
|
$455.44
|
|
|
Service Code
|
CPT 88305
|
| Hospital Charge Code |
Px03128830501
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$49.52 |
| Max. Negotiated Rate |
$364.35 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$321.09
|
| Rate for Payer: Aetna Workers' Compensation |
$321.09
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$315.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$315.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$358.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$358.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$358.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$350.69
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$358.89
|
| Rate for Payer: Cash Price |
$455.44
|
| Rate for Payer: Cash Price |
$455.44
|
| Rate for Payer: Cigna Commercial |
$238.65
|
| Rate for Payer: Cigna Medicare Advantage |
$259.60
|
| Rate for Payer: Family Health Partners Medicaid |
$65.77
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$286.93
|
| Rate for Payer: Healthy Blue Medicaid |
$71.03
|
| Rate for Payer: Home State Health Plan Exchange |
$259.60
|
| Rate for Payer: Home State Health Plan Medicaid |
$65.77
|
| Rate for Payer: Humana Medicare |
$341.58
|
| Rate for Payer: Mercy CarePlus Medicaid |
$65.77
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$341.58
|
| Rate for Payer: Provider Network of America Commercial |
$364.35
|
| Rate for Payer: UnitedHealthcare Commercial |
$300.59
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$52.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.52
|
|
|
Surg Path,Level IV - Lab Surg Path,Level IV
|
Facility
|
IP
|
$455.44
|
|
|
Service Code
|
CPT 88305
|
| Hospital Charge Code |
Px03128830501
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$341.58 |
| 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 |
$455.44
|
| Rate for Payer: Cash Price |
$455.44
|
| 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 |
$341.58
|
| Rate for Payer: Provider Network of America Commercial |
$364.35
|
|
|
Sutr Wnd Eyelid/Margin/Tarsus/Conjunc Full Thick
|
Professional
|
Both
|
$1,045.00
|
|
|
Service Code
|
CPT 67935
|
| Hospital Charge Code |
Px00000067935
|
|
Hospital Revenue Code
|
520
|
| Min. Negotiated Rate |
$435.35 |
| Max. Negotiated Rate |
$435.35 |
| Rate for Payer: Cash Price |
$1,045.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$435.35
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$17,299.60
|
|
|
Service Code
|
APR-DRG 2044
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$17,299.60 |
| 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: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$17,299.60
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$17,299.60
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$17,299.60
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$17,299.60
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 312
|
| 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 Freedom Network |
$3,791.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3,791.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| 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 |
$4,096.52
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$6,903.38
|
|
|
Service Code
|
APR-DRG 2041
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,903.38 |
| 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: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$6,903.38
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$6,903.38
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$6,903.38
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$6,903.38
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$10,411.01
|
|
|
Service Code
|
APR-DRG 2043
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$10,411.01 |
| 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: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$10,411.01
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$10,411.01
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$10,411.01
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$10,411.01
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$7,962.88
|
|
|
Service Code
|
APR-DRG 2042
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$7,962.88 |
| 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: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$7,962.88
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$7,962.88
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$7,962.88
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$7,962.88
|
|
|
Synvisc or Synvisc-One
|
Facility
|
IP
|
$1,870.69
|
|
|
Service Code
|
HCPCS J7325
|
| Hospital Charge Code |
Px0636J732501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$1,870.69
|
| Rate for Payer: Cash Price |
$1,870.69
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,403.02
|
| Rate for Payer: Provider Network of America Commercial |
$1,496.55
|
|
|
Synvisc or Synvisc-One
|
Facility
|
OP
|
$1,870.69
|
|
|
Service Code
|
HCPCS J7325
|
| Hospital Charge Code |
Px0636J732501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,066.29 |
| Max. Negotiated Rate |
$1,870.69 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,318.84
|
| Rate for Payer: Aetna Workers' Compensation |
$1,318.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,296.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,296.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,474.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,474.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,474.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$1,440.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,474.10
|
| Rate for Payer: Cash Price |
$1,870.69
|
| Rate for Payer: Cigna Commercial |
$1,144.86
|
| Rate for Payer: Cigna Medicare Advantage |
$1,066.29
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,178.53
|
| Rate for Payer: Home State Health Plan Exchange |
$1,066.29
|
| Rate for Payer: Humana Medicare |
$1,403.02
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,403.02
|
| Rate for Payer: Provider Network of America Commercial |
$1,496.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,234.66
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,870.69
|
|
|
Syringe Inflation 50ml
|
Facility
|
OP
|
$3.41
|
|
| Hospital Charge Code |
Px02720000082
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$3.41 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2.40
|
| Rate for Payer: Aetna Workers' Compensation |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$2.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$2.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$2.69
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$2.69
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$2.69
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$2.63
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$2.69
|
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Cigna Commercial |
$2.09
|
| Rate for Payer: Cigna Medicare Advantage |
$1.94
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2.15
|
| Rate for Payer: Home State Health Plan Exchange |
$1.94
|
| Rate for Payer: Humana Medicare |
$2.56
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2.56
|
| Rate for Payer: Provider Network of America Commercial |
$2.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.25
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$3.41
|
|
|
Syringe Inflation 50ml
|
Facility
|
IP
|
$3.41
|
|
| Hospital Charge Code |
Px02720000082
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.56 |
| 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 |
$3.41
|
| Rate for Payer: Cash Price |
$3.41
|
| 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 |
$2.56
|
| Rate for Payer: Provider Network of America Commercial |
$2.73
|
|
|
tamsulosin 0.4 mg capsule 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904738361
|
|
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
|
|
|
tamsulosin 0.4 mg capsule 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904738361
|
|
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
|
|
|
tamsulosin 0.4 mg capsule 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50268074011
|
|
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
|
|
|
tamsulosin 0.4 mg capsule 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50268074011
|
|
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
|
|
|
tamsulosin 0.4 mg capsule 50 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50268074015
|
|
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
|
|
|
tamsulosin 0.4 mg capsule 50 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50268074015
|
|
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
|
|
|
Tape Silicone 2"
|
Facility
|
OP
|
$106.09
|
|
| Hospital Charge Code |
Px02700000078
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$60.47 |
| Max. Negotiated Rate |
$106.09 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$74.79
|
| Rate for Payer: Aetna Workers' Compensation |
$74.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$73.52
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$73.52
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$83.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$83.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$83.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$81.69
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$83.60
|
| Rate for Payer: Cash Price |
$106.09
|
| Rate for Payer: Cigna Commercial |
$64.93
|
| Rate for Payer: Cigna Medicare Advantage |
$60.47
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$66.84
|
| Rate for Payer: Home State Health Plan Exchange |
$60.47
|
| Rate for Payer: Humana Medicare |
$79.57
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$79.57
|
| Rate for Payer: Provider Network of America Commercial |
$84.87
|
| Rate for Payer: UnitedHealthcare Commercial |
$70.02
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$106.09
|
|
|
Tape Silicone 2"
|
Facility
|
IP
|
$106.09
|
|
| Hospital Charge Code |
Px02700000078
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$79.57 |
| 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 |
$106.09
|
| Rate for Payer: Cash Price |
$106.09
|
| 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 |
$79.57
|
| Rate for Payer: Provider Network of America Commercial |
$84.87
|
|
|
tbo-filgrastim 300 mcg/0.5 mL syringe 0.5 mL Syringe
|
Facility
|
OP
|
$999.44
|
|
|
Service Code
|
HCPCS J1447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$569.68 |
| Max. Negotiated Rate |
$999.44 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$704.61
|
| Rate for Payer: Aetna Workers' Compensation |
$704.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$692.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$692.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$787.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$787.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$787.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$769.57
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$787.56
|
| Rate for Payer: Cash Price |
$999.44
|
| Rate for Payer: Cigna Commercial |
$611.66
|
| Rate for Payer: Cigna Medicare Advantage |
$569.68
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$629.65
|
| Rate for Payer: Home State Health Plan Exchange |
$569.68
|
| Rate for Payer: Humana Medicare |
$749.58
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$749.58
|
| Rate for Payer: Provider Network of America Commercial |
$799.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$659.63
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$999.44
|
|
|
tbo-filgrastim 300 mcg/0.5 mL syringe 0.5 mL Syringe
|
Facility
|
IP
|
$999.44
|
|
|
Service Code
|
NDC 63459091001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$749.58 |
| 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 |
$999.44
|
| Rate for Payer: Cash Price |
$999.44
|
| 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 |
$749.58
|
| Rate for Payer: Provider Network of America Commercial |
$799.55
|
|
|
tbo-filgrastim 300 mcg/0.5 mL syringe 0.5 mL Syringe
|
Facility
|
IP
|
$999.44
|
|
|
Service Code
|
HCPCS J1447
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$749.58 |
| 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 |
$999.44
|
| Rate for Payer: Cash Price |
$999.44
|
| 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 |
$749.58
|
| Rate for Payer: Provider Network of America Commercial |
$799.55
|
|
|
tbo-filgrastim 300 mcg/0.5 mL syringe 0.5 mL Syringe
|
Facility
|
OP
|
$999.44
|
|
|
Service Code
|
NDC 63459091011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$569.68 |
| Max. Negotiated Rate |
$999.44 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$704.61
|
| Rate for Payer: Aetna Workers' Compensation |
$704.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$692.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$692.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$787.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$787.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$787.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$769.57
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$787.56
|
| Rate for Payer: Cash Price |
$999.44
|
| Rate for Payer: Cigna Commercial |
$611.66
|
| Rate for Payer: Cigna Medicare Advantage |
$569.68
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$629.65
|
| Rate for Payer: Home State Health Plan Exchange |
$569.68
|
| Rate for Payer: Humana Medicare |
$749.58
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$749.58
|
| Rate for Payer: Provider Network of America Commercial |
$799.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$659.63
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$999.44
|
|
|
tbo-filgrastim 300 mcg/0.5 mL syringe 0.5 mL Syringe
|
Facility
|
IP
|
$999.44
|
|
|
Service Code
|
NDC 63459091011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$749.58 |
| 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 |
$999.44
|
| Rate for Payer: Cash Price |
$999.44
|
| 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 |
$749.58
|
| Rate for Payer: Provider Network of America Commercial |
$799.55
|
|
