|
Diazepam Injection
|
Facility
|
OP
|
$67.95
|
|
|
Service Code
|
CPT J3360
|
| Hospital Charge Code |
Px0636J336001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$67.95 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$47.90
|
| Rate for Payer: Aetna Workers' Compensation |
$47.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$47.09
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$47.09
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$53.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$53.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$53.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$52.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$53.54
|
| Rate for Payer: Cash Price |
$67.95
|
| Rate for Payer: Cigna Commercial |
$41.59
|
| Rate for Payer: Cigna Medicare Advantage |
$38.73
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$42.81
|
| Rate for Payer: Home State Health Plan Exchange |
$38.73
|
| Rate for Payer: Humana Medicare |
$50.96
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$50.96
|
| Rate for Payer: Provider Network of America Commercial |
$54.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$44.85
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$67.95
|
|
|
diclofenac sodium 1 % gel 100 g Tube
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 69097052444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$45.00
|
| Rate for Payer: Provider Network of America Commercial |
$48.00
|
|
|
diclofenac sodium 1 % gel 100 g Tube
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 69097052444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.20 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$42.30
|
| Rate for Payer: Aetna Workers' Compensation |
$42.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$41.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$41.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$47.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$47.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$47.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$46.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$47.28
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$36.72
|
| Rate for Payer: Cigna Medicare Advantage |
$34.20
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$37.80
|
| Rate for Payer: Home State Health Plan Exchange |
$34.20
|
| Rate for Payer: Humana Medicare |
$45.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$45.00
|
| Rate for Payer: Provider Network of America Commercial |
$48.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$39.60
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$60.00
|
|
|
diclofenac sodium 1 % gel 100 g Tube
|
Facility
|
IP
|
$51.04
|
|
|
Service Code
|
NDC 00536129497
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.28 |
| 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 |
$51.04
|
| Rate for Payer: Cash Price |
$51.04
|
| 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 |
$38.28
|
| Rate for Payer: Provider Network of America Commercial |
$40.83
|
|
|
diclofenac sodium 1 % gel 100 g Tube
|
Facility
|
OP
|
$57.08
|
|
|
Service Code
|
NDC 00067815203
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.54 |
| Max. Negotiated Rate |
$57.08 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$40.24
|
| Rate for Payer: Aetna Workers' Compensation |
$40.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$39.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$39.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$44.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$44.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$44.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$43.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$44.98
|
| Rate for Payer: Cash Price |
$57.08
|
| Rate for Payer: Cigna Commercial |
$34.93
|
| Rate for Payer: Cigna Medicare Advantage |
$32.54
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$35.96
|
| Rate for Payer: Home State Health Plan Exchange |
$32.54
|
| Rate for Payer: Humana Medicare |
$42.81
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$42.81
|
| Rate for Payer: Provider Network of America Commercial |
$45.66
|
| Rate for Payer: UnitedHealthcare Commercial |
$37.67
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$57.08
|
|
|
diclofenac sodium 1 % gel 100 g Tube
|
Facility
|
IP
|
$57.08
|
|
|
Service Code
|
NDC 00067815203
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.81 |
| 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 |
$57.08
|
| Rate for Payer: Cash Price |
$57.08
|
| 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 |
$42.81
|
| Rate for Payer: Provider Network of America Commercial |
$45.66
|
|
|
diclofenac sodium 1 % gel 100 g Tube
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
NDC 45802095301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.93 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$34.55
|
| Rate for Payer: Aetna Workers' Compensation |
$34.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$33.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$33.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$38.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$38.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$38.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$37.73
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$38.61
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: Cigna Commercial |
$29.99
|
| Rate for Payer: Cigna Medicare Advantage |
$27.93
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$30.87
|
| Rate for Payer: Home State Health Plan Exchange |
$27.93
|
| Rate for Payer: Humana Medicare |
$36.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$36.75
|
| Rate for Payer: Provider Network of America Commercial |
$39.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$32.34
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$49.00
|
|
|
diclofenac sodium 1 % gel 100 g Tube
|
Facility
|
OP
|
$51.04
|
|
|
Service Code
|
NDC 00536129497
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.09 |
| Max. Negotiated Rate |
$51.04 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$35.98
|
| Rate for Payer: Aetna Workers' Compensation |
$35.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$35.37
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$35.37
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$40.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$40.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$40.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$39.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$40.22
|
| Rate for Payer: Cash Price |
$51.04
|
| Rate for Payer: Cigna Commercial |
$31.24
|
| Rate for Payer: Cigna Medicare Advantage |
$29.09
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$32.16
|
| Rate for Payer: Home State Health Plan Exchange |
$29.09
|
| Rate for Payer: Humana Medicare |
$38.28
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$38.28
|
| Rate for Payer: Provider Network of America Commercial |
$40.83
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.69
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$51.04
|
|
|
diclofenac sodium 1 % gel 100 g Tube
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
NDC 45802095301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.75 |
| 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 |
$49.00
|
| Rate for Payer: Cash Price |
$49.00
|
| 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 |
$36.75
|
| Rate for Payer: Provider Network of America Commercial |
$39.20
|
|
|
dicyclomine 10 mg/mL solution 2 mL Vial
|
Facility
|
OP
|
$49.20
|
|
|
Service Code
|
NDC 72266012701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.04 |
| Max. Negotiated Rate |
$49.20 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$34.69
|
| Rate for Payer: Aetna Workers' Compensation |
$34.69
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$34.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$34.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$38.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$38.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$38.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$37.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$38.77
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$30.11
|
| Rate for Payer: Cigna Medicare Advantage |
$28.04
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$31.00
|
| Rate for Payer: Home State Health Plan Exchange |
$28.04
|
| Rate for Payer: Humana Medicare |
$36.90
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$36.90
|
| Rate for Payer: Provider Network of America Commercial |
$39.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$32.47
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$49.20
|
|
|
dicyclomine 10 mg/mL solution 2 mL Vial
|
Facility
|
IP
|
$49.20
|
|
|
Service Code
|
HCPCS J0500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.90 |
| 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 |
$49.20
|
| Rate for Payer: Cash Price |
$49.20
|
| 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 |
$36.90
|
| Rate for Payer: Provider Network of America Commercial |
$39.36
|
|
|
dicyclomine 10 mg/mL solution 2 mL Vial
|
Facility
|
OP
|
$49.20
|
|
|
Service Code
|
HCPCS J0500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.04 |
| Max. Negotiated Rate |
$49.20 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$34.69
|
| Rate for Payer: Aetna Workers' Compensation |
$34.69
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$34.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$34.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$38.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$38.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$38.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$37.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$38.77
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$30.11
|
| Rate for Payer: Cigna Medicare Advantage |
$28.04
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$31.00
|
| Rate for Payer: Home State Health Plan Exchange |
$28.04
|
| Rate for Payer: Humana Medicare |
$36.90
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$36.90
|
| Rate for Payer: Provider Network of America Commercial |
$39.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$32.47
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$49.20
|
|
|
dicyclomine 10 mg/mL solution 2 mL Vial
|
Facility
|
IP
|
$49.20
|
|
|
Service Code
|
NDC 72266012701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.90 |
| 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 |
$49.20
|
| Rate for Payer: Cash Price |
$49.20
|
| 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 |
$36.90
|
| Rate for Payer: Provider Network of America Commercial |
$39.36
|
|
|
dicyclomine 20 mg tablet 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904698861
|
|
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
|
|
|
dicyclomine 20 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904698861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: UnitedHealthcare Commercial |
$2.64
|
| 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 Individual Exchange |
$4.00
|
|
|
Dicyclomine injection
|
Facility
|
OP
|
$82.95
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
Px0636J050001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.28 |
| Max. Negotiated Rate |
$82.95 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$58.48
|
| Rate for Payer: Aetna Workers' Compensation |
$58.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$57.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$57.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$65.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$65.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$65.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$63.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$65.36
|
| Rate for Payer: Cash Price |
$82.95
|
| Rate for Payer: Cigna Commercial |
$50.77
|
| Rate for Payer: Cigna Medicare Advantage |
$47.28
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$52.26
|
| Rate for Payer: Home State Health Plan Exchange |
$47.28
|
| Rate for Payer: Humana Medicare |
$62.21
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$62.21
|
| Rate for Payer: Provider Network of America Commercial |
$66.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$54.75
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$82.95
|
|
|
Dicyclomine injection
|
Facility
|
IP
|
$82.95
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
Px0636J050001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.21 |
| 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 |
$82.95
|
| Rate for Payer: Cash Price |
$82.95
|
| 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 |
$62.21
|
| Rate for Payer: Provider Network of America Commercial |
$66.36
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$9,896.05
|
|
|
Service Code
|
APR-DRG 2402
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$9,896.05 |
| 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 |
$9,896.05
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$9,896.05
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$9,896.05
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$9,896.05
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$15,191.70
|
|
|
Service Code
|
APR-DRG 2403
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$15,191.70 |
| 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 |
$15,191.70
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$15,191.70
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$15,191.70
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$15,191.70
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$8,309.58
|
|
|
Service Code
|
APR-DRG 2401
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$8,309.58 |
| 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 |
$8,309.58
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$8,309.58
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$8,309.58
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$8,309.58
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$25,023.03
|
|
|
Service Code
|
APR-DRG 2404
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$25,023.03 |
| 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 |
$25,023.03
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$25,023.03
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$25,023.03
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$25,023.03
|
|
|
DIGESTIVE MALIGNANCY WITH CC
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 375
|
| 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 |
$5,685.12
|
|
|
DIGESTIVE MALIGNANCY WITH MCC
|
Facility
|
IP
|
$10,051.89
|
|
|
Service Code
|
MSDRG 374
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$10,051.89 |
| 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 |
$10,051.89
|
|
|
DIGESTIVE MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 376
|
| 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 |
$4,344.21
|
|
|
Digital Breast Tomosynthesis Bilateral
|
Facility
|
OP
|
$30.03
|
|
|
Service Code
|
CPT 77062
|
| Hospital Charge Code |
Px09727706201
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$17.12 |
| Max. Negotiated Rate |
$30.03 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$21.17
|
| Rate for Payer: Aetna Workers' Compensation |
$21.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$20.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$20.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$23.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$23.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$23.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$23.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$23.66
|
| Rate for Payer: Cash Price |
$30.03
|
| Rate for Payer: Cigna Commercial |
$18.38
|
| Rate for Payer: Cigna Medicare Advantage |
$17.12
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$18.92
|
| Rate for Payer: Home State Health Plan Exchange |
$17.12
|
| Rate for Payer: Humana Medicare |
$22.52
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$22.52
|
| Rate for Payer: Provider Network of America Commercial |
$24.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.82
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$30.03
|
|
