|
DOCEtaxel 20 mg/mL (1 mL) solution 1 mL Vial
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
NDC 25021024501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$75.00
|
| Rate for Payer: Provider Network of America Commercial |
$80.00
|
|
|
Docetaxel injection
|
Facility
|
OP
|
$101.59
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
Px0636J917101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.91 |
| Max. Negotiated Rate |
$101.59 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$71.62
|
| Rate for Payer: Aetna Workers' Compensation |
$71.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$70.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$70.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$80.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$80.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$80.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$78.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$80.05
|
| Rate for Payer: Cash Price |
$101.59
|
| Rate for Payer: Cigna Commercial |
$62.17
|
| Rate for Payer: Cigna Medicare Advantage |
$57.91
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$64.00
|
| Rate for Payer: Home State Health Plan Exchange |
$57.91
|
| Rate for Payer: Humana Medicare |
$76.19
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$76.19
|
| Rate for Payer: Provider Network of America Commercial |
$81.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$67.05
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$101.59
|
|
|
Docetaxel injection
|
Facility
|
IP
|
$101.59
|
|
|
Service Code
|
HCPCS J9171
|
| Hospital Charge Code |
Px0636J917101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.19 |
| 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 |
$101.59
|
| Rate for Payer: Cash Price |
$101.59
|
| 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 |
$76.19
|
| Rate for Payer: Provider Network of America Commercial |
$81.27
|
|
|
docetaxel per 1 mg
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
HCPCS J9171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$255.00 |
| 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 |
$340.00
|
| Rate for Payer: Cash Price |
$340.00
|
| 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 |
$255.00
|
| Rate for Payer: Provider Network of America Commercial |
$272.00
|
|
|
docetaxel per 1 mg
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
NDC 25021024504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$255.00 |
| 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 |
$340.00
|
| Rate for Payer: Cash Price |
$340.00
|
| 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 |
$255.00
|
| Rate for Payer: Provider Network of America Commercial |
$272.00
|
|
|
docetaxel per 1 mg
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
NDC 25021024504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$193.80 |
| Max. Negotiated Rate |
$340.00 |
| Rate for Payer: Aetna Workers' Compensation |
$239.70
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$239.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$235.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$235.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$267.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$267.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$267.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$261.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$267.92
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cigna Commercial |
$208.08
|
| Rate for Payer: Cigna Medicare Advantage |
$193.80
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$214.20
|
| Rate for Payer: Home State Health Plan Exchange |
$193.80
|
| Rate for Payer: Humana Medicare |
$255.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$255.00
|
| Rate for Payer: Provider Network of America Commercial |
$272.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$224.40
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$340.00
|
|
|
docetaxel per 1 mg
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
HCPCS J9171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$193.80 |
| Max. Negotiated Rate |
$340.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$239.70
|
| Rate for Payer: Aetna Workers' Compensation |
$239.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$235.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$235.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$267.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$267.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$267.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$261.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$267.92
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cigna Commercial |
$208.08
|
| Rate for Payer: Cigna Medicare Advantage |
$193.80
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$214.20
|
| Rate for Payer: Home State Health Plan Exchange |
$193.80
|
| Rate for Payer: Humana Medicare |
$255.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$255.00
|
| Rate for Payer: Provider Network of America Commercial |
$272.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$224.40
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$340.00
|
|
|
docusate sodium 100 mg capsule 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904718361
|
|
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
|
|
|
docusate sodium 100 mg capsule 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904718361
|
|
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
|
|
|
docusate sodium 10 mg/mL liquid 10 mL Cup
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00121187010
|
|
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
|
|
|
docusate sodium 10 mg/mL liquid 10 mL Cup
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00121187010
|
|
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
|
|
|
Dolasetron mesylate
|
Facility
|
IP
|
$246.92
|
|
|
Service Code
|
HCPCS J1260
|
| Hospital Charge Code |
Px0636J126001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$185.19 |
| 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 |
$246.92
|
| Rate for Payer: Cash Price |
$246.92
|
| 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 |
$185.19
|
| Rate for Payer: Provider Network of America Commercial |
$197.54
|
|
|
Dolasetron mesylate
|
Facility
|
OP
|
$246.92
|
|
|
Service Code
|
HCPCS J1260
|
| Hospital Charge Code |
Px0636J126001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$140.74 |
| Max. Negotiated Rate |
$246.92 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$174.08
|
| Rate for Payer: Aetna Workers' Compensation |
$174.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$171.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$171.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$194.57
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$194.57
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$194.57
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$190.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$194.57
|
| Rate for Payer: Cash Price |
$246.92
|
| Rate for Payer: Cigna Commercial |
$151.12
|
| Rate for Payer: Cigna Medicare Advantage |
$140.74
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$155.56
|
| Rate for Payer: Home State Health Plan Exchange |
$140.74
|
| Rate for Payer: Humana Medicare |
$185.19
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$185.19
|
| Rate for Payer: Provider Network of America Commercial |
$197.54
|
| Rate for Payer: UnitedHealthcare Commercial |
$162.97
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$246.92
|
|
|
donepezil 5 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904647761
|
|
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
|
|
|
donepezil 5 mg tablet 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904647761
|
|
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
|
|
|
DOPamine 400 mg/250 mL (1,600 mcg/mL) solution 250 mL Bag
|
Facility
|
IP
|
$63.49
|
|
|
Service Code
|
HCPCS J1265
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.62 |
| 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 |
$63.49
|
| Rate for Payer: Cash Price |
$63.49
|
| 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 |
$47.62
|
| Rate for Payer: Provider Network of America Commercial |
$50.79
|
|
|
DOPamine 400 mg/250 mL (1,600 mcg/mL) solution 250 mL Bag
|
Facility
|
IP
|
$63.49
|
|
|
Service Code
|
NDC 00409780911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.62 |
| 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 |
$63.49
|
| Rate for Payer: Cash Price |
$63.49
|
| 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 |
$47.62
|
| Rate for Payer: Provider Network of America Commercial |
$50.79
|
|
|
DOPamine 400 mg/250 mL (1,600 mcg/mL) solution 250 mL Bag
|
Facility
|
OP
|
$63.49
|
|
|
Service Code
|
HCPCS J1265
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.19 |
| Max. Negotiated Rate |
$63.49 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$44.76
|
| Rate for Payer: Aetna Workers' Compensation |
$44.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$44.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$44.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$50.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$50.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$50.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$48.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$50.03
|
| Rate for Payer: Cash Price |
$63.49
|
| Rate for Payer: Cigna Commercial |
$38.86
|
| Rate for Payer: Cigna Medicare Advantage |
$36.19
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$40.00
|
| Rate for Payer: Home State Health Plan Exchange |
$36.19
|
| Rate for Payer: Humana Medicare |
$47.62
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$47.62
|
| Rate for Payer: Provider Network of America Commercial |
$50.79
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.90
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$63.49
|
|
|
DOPamine 400 mg/250 mL (1,600 mcg/mL) solution 250 mL Bag
|
Facility
|
OP
|
$63.49
|
|
|
Service Code
|
NDC 00409780911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.19 |
| Max. Negotiated Rate |
$63.49 |
| Rate for Payer: Aetna Workers' Compensation |
$44.76
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$44.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$44.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$44.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$50.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$50.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$50.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$48.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$50.03
|
| Rate for Payer: Cash Price |
$63.49
|
| Rate for Payer: Cigna Commercial |
$38.86
|
| Rate for Payer: Cigna Medicare Advantage |
$36.19
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$40.00
|
| Rate for Payer: Home State Health Plan Exchange |
$36.19
|
| Rate for Payer: Humana Medicare |
$47.62
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$47.62
|
| Rate for Payer: Provider Network of America Commercial |
$50.79
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.90
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$63.49
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$25,823.66
|
|
|
Service Code
|
APR-DRG 3041
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$25,823.66 |
| 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 |
$25,823.66
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$25,823.66
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$25,823.66
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$25,823.66
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$68,788.84
|
|
|
Service Code
|
APR-DRG 3044
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$68,788.84 |
| 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 |
$68,788.84
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$68,788.84
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$68,788.84
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$68,788.84
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$34,916.31
|
|
|
Service Code
|
APR-DRG 3042
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$34,916.31 |
| 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 |
$34,916.31
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$34,916.31
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$34,916.31
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$34,916.31
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$48,868.23
|
|
|
Service Code
|
APR-DRG 3043
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$48,868.23 |
| 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 |
$48,868.23
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$48,868.23
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$48,868.23
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$48,868.23
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$98,344.78
|
|
|
Service Code
|
APR-DRG 3034
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$98,344.78 |
| 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 |
$98,344.78
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$98,344.78
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$98,344.78
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$98,344.78
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$47,293.77
|
|
|
Service Code
|
APR-DRG 3032
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$47,293.77 |
| 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 |
$47,293.77
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$47,293.77
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$47,293.77
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$47,293.77
|
|
