|
Tenotomy Percutaneous Toe Multiple Tendon
|
Facility
|
IP
|
$3,465.00
|
|
|
Service Code
|
CPT 28011
|
| Hospital Charge Code |
Px07612801101
|
|
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
|
|
|
terbutaline 1 mg/mL solution 1 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J3105
|
|
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
|
|
|
terbutaline 1 mg/mL solution 1 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00143974610
|
|
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
|
|
|
terbutaline 1 mg/mL solution 1 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00143974601
|
|
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
|
|
|
terbutaline 1 mg/mL solution 1 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00143974601
|
|
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
|
|
|
terbutaline 1 mg/mL solution 1 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00143974610
|
|
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
|
|
|
terbutaline 1 mg/mL solution 1 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J3105
|
|
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
|
|
|
Terbutaline sulfate inj
|
Facility
|
OP
|
$26.25
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
Px0636J310501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$18.51
|
| Rate for Payer: Aetna Workers' Compensation |
$18.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$18.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$18.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$20.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$20.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$20.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$20.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$20.68
|
| Rate for Payer: Cash Price |
$26.25
|
| Rate for Payer: Cigna Commercial |
$16.07
|
| Rate for Payer: Cigna Medicare Advantage |
$14.96
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$16.54
|
| Rate for Payer: Home State Health Plan Exchange |
$14.96
|
| Rate for Payer: Humana Medicare |
$19.69
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$19.69
|
| Rate for Payer: Provider Network of America Commercial |
$21.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.32
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$26.25
|
|
|
Terbutaline sulfate inj
|
Facility
|
IP
|
$26.25
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
Px0636J310501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.69 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$26.25
|
| Rate for Payer: Cash Price |
$26.25
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$19.69
|
| Rate for Payer: Provider Network of America Commercial |
$21.00
|
|
|
TESTES PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$9,793.86
|
|
|
Service Code
|
MSDRG 711
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$9,793.86 |
| 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: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$9,793.86
|
|
|
TESTES PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 712
|
| 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: 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 |
$5,168.59
|
|
|
testosterone cypionate 200 mg/mL oil 1 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00009041701
|
|
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
|
|
|
testosterone cypionate 200 mg/mL oil 1 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J1071
|
|
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
|
|
|
testosterone cypionate 200 mg/mL oil 1 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00009008601
|
|
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
|
|
|
testosterone cypionate 200 mg/mL oil 1 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00009008601
|
|
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
|
|
|
testosterone cypionate 200 mg/mL oil 1 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J1071
|
|
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
|
|
|
testosterone cypionate 200 mg/mL oil 1 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00009041701
|
|
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
|
|
|
tetanus-diphtheris toxoids (Td) (PF) 5-2 Lf unit/0.5 mL syringe 0.5 mL Syringe
|
Facility
|
IP
|
$177.65
|
|
|
Service Code
|
CPT 90714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$133.24 |
| 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 |
$177.65
|
| Rate for Payer: Cash Price |
$177.65
|
| 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 |
$133.24
|
| Rate for Payer: Provider Network of America Commercial |
$142.12
|
|
|
tetanus-diphtheris toxoids (Td) (PF) 5-2 Lf unit/0.5 mL syringe 0.5 mL Syringe
|
Facility
|
OP
|
$177.65
|
|
|
Service Code
|
NDC 49281021515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$101.26 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Aetna Workers' Compensation |
$125.24
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$125.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$123.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$123.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$139.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$139.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$139.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$136.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$139.99
|
| Rate for Payer: Cash Price |
$177.65
|
| Rate for Payer: Cigna Commercial |
$108.72
|
| Rate for Payer: Cigna Medicare Advantage |
$101.26
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$111.92
|
| Rate for Payer: Home State Health Plan Exchange |
$101.26
|
| Rate for Payer: Humana Medicare |
$133.24
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$133.24
|
| Rate for Payer: Provider Network of America Commercial |
$142.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$117.25
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$177.65
|
|
|
tetanus-diphtheris toxoids (Td) (PF) 5-2 Lf unit/0.5 mL syringe 0.5 mL Syringe
|
Facility
|
OP
|
$177.65
|
|
|
Service Code
|
CPT 90714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$125.24
|
| Rate for Payer: Aetna Workers' Compensation |
$125.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$123.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$123.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$139.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$139.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$139.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$136.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$139.99
|
| Rate for Payer: Cash Price |
$177.65
|
| Rate for Payer: Cash Price |
$177.65
|
| Rate for Payer: Cigna Commercial |
$108.72
|
| Rate for Payer: Cigna Medicare Advantage |
$101.26
|
| Rate for Payer: Family Health Partners Medicaid |
$22.58
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$111.92
|
| Rate for Payer: Healthy Blue Medicaid |
$24.39
|
| Rate for Payer: Home State Health Plan Exchange |
$101.26
|
| Rate for Payer: Home State Health Plan Medicaid |
$22.58
|
| Rate for Payer: Humana Medicare |
$133.24
|
| Rate for Payer: Mercy CarePlus Medicaid |
$22.58
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$133.24
|
| Rate for Payer: Provider Network of America Commercial |
$142.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$117.25
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$177.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.00
|
|
|
tetanus-diphtheris toxoids (Td) (PF) 5-2 Lf unit/0.5 mL syringe 0.5 mL Syringe
|
Facility
|
IP
|
$177.65
|
|
|
Service Code
|
NDC 49281021515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$133.24 |
| 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 |
$177.65
|
| Rate for Payer: Cash Price |
$177.65
|
| 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 |
$133.24
|
| Rate for Payer: Provider Network of America Commercial |
$142.12
|
|
|
tetracaine (PF) 0.5 % drops 4 mL DROP BTL
|
Facility
|
IP
|
$55.52
|
|
|
Service Code
|
NDC 00065074114
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.64 |
| 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 |
$55.52
|
| Rate for Payer: Cash Price |
$55.52
|
| 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 |
$41.64
|
| Rate for Payer: Provider Network of America Commercial |
$44.42
|
|
|
tetracaine (PF) 0.5 % drops 4 mL DROP BTL
|
Facility
|
OP
|
$55.52
|
|
|
Service Code
|
NDC 00065074114
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.65 |
| Max. Negotiated Rate |
$55.52 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$39.14
|
| Rate for Payer: Aetna Workers' Compensation |
$39.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$38.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$38.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$43.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$43.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$43.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$42.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$43.75
|
| Rate for Payer: Cash Price |
$55.52
|
| Rate for Payer: Cigna Commercial |
$33.98
|
| Rate for Payer: Cigna Medicare Advantage |
$31.65
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$34.98
|
| Rate for Payer: Home State Health Plan Exchange |
$31.65
|
| Rate for Payer: Humana Medicare |
$41.64
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$41.64
|
| Rate for Payer: Provider Network of America Commercial |
$44.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.64
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$55.52
|
|
|
Therahoney Foam Flex 4x4
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
CPT A6209
|
| Hospital Charge Code |
Px0270A620901
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.41 |
| Max. Negotiated Rate |
$13.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$9.16
|
| Rate for Payer: Aetna Workers' Compensation |
$9.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$9.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$9.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$10.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$10.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$10.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$10.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$10.24
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cigna Commercial |
$7.96
|
| Rate for Payer: Cigna Medicare Advantage |
$7.41
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$8.19
|
| Rate for Payer: Home State Health Plan Exchange |
$7.41
|
| Rate for Payer: Humana Medicare |
$9.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$9.75
|
| Rate for Payer: Provider Network of America Commercial |
$10.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.58
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$13.00
|
|
|
Therahoney Foam Flex 4x4
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
CPT A6209
|
| Hospital Charge Code |
Px0270A620901
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cash Price |
$13.00
|
| 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 |
$9.75
|
| Rate for Payer: Provider Network of America Commercial |
$10.40
|
|
