|
Dressing Maxorb Rope 1x12
|
Facility
|
OP
|
$15.59
|
|
|
Service Code
|
HCPCS A6199
|
| Hospital Charge Code |
Px0272A619901
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.89 |
| Max. Negotiated Rate |
$15.59 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$10.99
|
| Rate for Payer: Aetna Workers' Compensation |
$10.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$10.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$10.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$12.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$12.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$12.28
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$12.28
|
| Rate for Payer: Cash Price |
$15.59
|
| Rate for Payer: Cigna Commercial |
$9.54
|
| Rate for Payer: Cigna Medicare Advantage |
$8.89
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$9.82
|
| Rate for Payer: Home State Health Plan Exchange |
$8.89
|
| Rate for Payer: Humana Medicare |
$11.69
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$11.69
|
| Rate for Payer: Provider Network of America Commercial |
$12.47
|
| Rate for Payer: UnitedHealthcare Commercial |
$10.29
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$15.59
|
|
|
Dressing Maxorb Rope 1x12
|
Facility
|
IP
|
$15.59
|
|
|
Service Code
|
HCPCS A6199
|
| Hospital Charge Code |
Px0272A619901
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.69 |
| 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 |
$15.59
|
| Rate for Payer: Cash Price |
$15.59
|
| 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 |
$11.69
|
| Rate for Payer: Provider Network of America Commercial |
$12.47
|
|
|
Dressing Medfix 2"
|
Facility
|
OP
|
$106.09
|
|
|
Service Code
|
CPT A4452
|
| Hospital Charge Code |
Px0270A445201
|
|
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
|
|
|
Dressing Medfix 2"
|
Facility
|
IP
|
$106.09
|
|
|
Service Code
|
CPT A4452
|
| Hospital Charge Code |
Px0270A445201
|
|
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
|
|
|
Dressing Medfix 4 "
|
Facility
|
OP
|
$106.09
|
|
|
Service Code
|
CPT A4452
|
| Hospital Charge Code |
Px0270A445202
|
|
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
|
|
|
Dressing Medfix 4 "
|
Facility
|
IP
|
$106.09
|
|
|
Service Code
|
CPT A4452
|
| Hospital Charge Code |
Px0270A445202
|
|
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
|
|
|
Dressing Mepilex Post-OP 4x12
|
Facility
|
OP
|
$83.40
|
|
|
Service Code
|
CPT A6213
|
| Hospital Charge Code |
Px0272A621301
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.54 |
| Max. Negotiated Rate |
$83.40 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$58.80
|
| Rate for Payer: Aetna Workers' Compensation |
$58.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$57.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$57.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$65.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$65.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$65.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$64.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$65.72
|
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Cigna Commercial |
$51.04
|
| Rate for Payer: Cigna Medicare Advantage |
$47.54
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$52.54
|
| Rate for Payer: Home State Health Plan Exchange |
$47.54
|
| Rate for Payer: Humana Medicare |
$62.55
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$62.55
|
| Rate for Payer: Provider Network of America Commercial |
$66.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$55.04
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$83.40
|
|
|
Dressing Mepilex Post-OP 4x12
|
Facility
|
IP
|
$83.40
|
|
|
Service Code
|
CPT A6213
|
| Hospital Charge Code |
Px0272A621301
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$62.55 |
| 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 |
$83.40
|
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$62.55
|
| Rate for Payer: Provider Network of America Commercial |
$66.72
|
|
|
Dressing Opticell 4x5 Ag
|
Facility
|
OP
|
$12.97
|
|
|
Service Code
|
HCPCS A6197
|
| Hospital Charge Code |
Px0272A619701
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.39 |
| Max. Negotiated Rate |
$12.97 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$9.14
|
| Rate for Payer: Aetna Workers' Compensation |
$9.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$8.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$8.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$10.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$10.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$10.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$9.99
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$10.22
|
| Rate for Payer: Cash Price |
$12.97
|
| Rate for Payer: Cigna Commercial |
$7.94
|
| Rate for Payer: Cigna Medicare Advantage |
$7.39
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$8.17
|
| Rate for Payer: Home State Health Plan Exchange |
$7.39
|
| Rate for Payer: Humana Medicare |
$9.73
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$9.73
|
| Rate for Payer: Provider Network of America Commercial |
$10.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.56
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$12.97
|
|
|
Dressing Opticell 4x5 Ag
|
Facility
|
IP
|
$12.97
|
|
|
Service Code
|
HCPCS A6197
|
| Hospital Charge Code |
Px0272A619701
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.73 |
| 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 |
$12.97
|
| Rate for Payer: Cash Price |
$12.97
|
| 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 |
$9.73
|
| Rate for Payer: Provider Network of America Commercial |
$10.38
|
|
|
Dressing Optifoam 3x3
|
Facility
|
IP
|
$7.81
|
|
|
Service Code
|
CPT A6212
|
| Hospital Charge Code |
Px0272A621202
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.86 |
| 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 |
$7.81
|
| Rate for Payer: Cash Price |
$7.81
|
| 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 |
$5.86
|
| Rate for Payer: Provider Network of America Commercial |
$6.25
|
|
|
Dressing Optifoam 3x3
|
Facility
|
OP
|
$7.81
|
|
|
Service Code
|
CPT A6212
|
| Hospital Charge Code |
Px0272A621202
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$7.81 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5.51
|
| Rate for Payer: Aetna Workers' Compensation |
$5.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$6.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$6.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$6.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$6.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$6.15
|
| Rate for Payer: Cash Price |
$7.81
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Cigna Medicare Advantage |
$4.45
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$4.92
|
| Rate for Payer: Home State Health Plan Exchange |
$4.45
|
| Rate for Payer: Humana Medicare |
$5.86
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5.86
|
| Rate for Payer: Provider Network of America Commercial |
$6.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.15
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7.81
|
|
|
Dressing Optifoam 4x4
|
Facility
|
OP
|
$12.99
|
|
|
Service Code
|
CPT A6212
|
| Hospital Charge Code |
Px0272A621203
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.40 |
| Max. Negotiated Rate |
$12.99 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$9.16
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5.25
|
| Rate for Payer: Aetna Workers' Compensation |
$9.16
|
| Rate for Payer: Aetna Workers' Compensation |
$5.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$5.86
|
| 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 |
$5.86
|
| 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 |
$5.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$5.73
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$5.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$10.24
|
| Rate for Payer: Cash Price |
$7.44
|
| Rate for Payer: Cash Price |
$12.99
|
| Rate for Payer: Cigna Commercial |
$7.95
|
| Rate for Payer: Cigna Commercial |
$4.55
|
| Rate for Payer: Cigna Medicare Advantage |
$7.40
|
| Rate for Payer: Cigna Medicare Advantage |
$4.24
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$8.18
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$4.69
|
| Rate for Payer: Home State Health Plan Exchange |
$7.40
|
| Rate for Payer: Home State Health Plan Exchange |
$4.24
|
| Rate for Payer: Humana Medicare |
$9.74
|
| Rate for Payer: Humana Medicare |
$5.58
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$9.74
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5.58
|
| Rate for Payer: Provider Network of America Commercial |
$10.39
|
| Rate for Payer: Provider Network of America Commercial |
$5.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.91
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$12.99
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7.44
|
|
|
Dressing Optifoam 4x4
|
Facility
|
IP
|
$7.44
|
|
|
Service Code
|
CPT A6212
|
| Hospital Charge Code |
Px0272A621203
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.58 |
| 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 Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$7.44
|
| Rate for Payer: Cash Price |
$12.99
|
| Rate for Payer: Cash Price |
$12.99
|
| Rate for Payer: Cash Price |
$7.44
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$9.74
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5.58
|
| Rate for Payer: Provider Network of America Commercial |
$10.39
|
| Rate for Payer: Provider Network of America Commercial |
$5.95
|
|
|
Dressing Optifoam Post-OP
|
Facility
|
IP
|
$35.26
|
|
|
Service Code
|
CPT A6254
|
| Hospital Charge Code |
Px0272A625401
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.45 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$35.26
|
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Cash Price |
$35.26
|
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.45
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2.56
|
| Rate for Payer: Provider Network of America Commercial |
$28.21
|
| Rate for Payer: Provider Network of America Commercial |
$2.73
|
|
|
Dressing Optifoam Post-OP
|
Facility
|
OP
|
$35.26
|
|
|
Service Code
|
CPT A6254
|
| Hospital Charge Code |
Px0272A625401
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.10 |
| Max. Negotiated Rate |
$35.26 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$24.86
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$2.40
|
| Rate for Payer: Aetna Workers' Compensation |
$2.40
|
| Rate for Payer: Aetna Workers' Compensation |
$24.86
|
| 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 Advantage (HMO) |
$24.44
|
| 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 Blue Care (HMO) |
$24.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$27.78
|
| 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 Freedom Network Select |
$27.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$27.78
|
| 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) |
$27.15
|
| 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: Blue Cross Blue Shield of Kansas City Traditional |
$27.78
|
| Rate for Payer: Cash Price |
$35.26
|
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Cigna Commercial |
$2.09
|
| Rate for Payer: Cigna Commercial |
$21.58
|
| Rate for Payer: Cigna Medicare Advantage |
$20.10
|
| Rate for Payer: Cigna Medicare Advantage |
$1.94
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$22.21
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2.15
|
| Rate for Payer: Home State Health Plan Exchange |
$1.94
|
| Rate for Payer: Home State Health Plan Exchange |
$20.10
|
| Rate for Payer: Humana Medicare |
$26.45
|
| Rate for Payer: Humana Medicare |
$2.56
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$2.56
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.45
|
| Rate for Payer: Provider Network of America Commercial |
$28.21
|
| Rate for Payer: Provider Network of America Commercial |
$2.73
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.27
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$3.41
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$35.26
|
|
|
Dressing Optifoam Sacrum
|
Facility
|
OP
|
$18.15
|
|
|
Service Code
|
CPT A6213
|
| Hospital Charge Code |
Px0272A621302
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.35 |
| Max. Negotiated Rate |
$18.15 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$12.80
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$13.44
|
| Rate for Payer: Aetna Workers' Compensation |
$12.80
|
| Rate for Payer: Aetna Workers' Compensation |
$13.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$12.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$13.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$12.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$13.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$15.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$14.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$15.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$14.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$14.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$15.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$13.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$14.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$15.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$14.30
|
| Rate for Payer: Cash Price |
$19.06
|
| Rate for Payer: Cash Price |
$18.15
|
| Rate for Payer: Cigna Commercial |
$11.11
|
| Rate for Payer: Cigna Commercial |
$11.66
|
| Rate for Payer: Cigna Medicare Advantage |
$10.35
|
| Rate for Payer: Cigna Medicare Advantage |
$10.86
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$11.43
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$12.01
|
| Rate for Payer: Home State Health Plan Exchange |
$10.35
|
| Rate for Payer: Home State Health Plan Exchange |
$10.86
|
| Rate for Payer: Humana Medicare |
$13.61
|
| Rate for Payer: Humana Medicare |
$14.29
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$13.61
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$14.29
|
| Rate for Payer: Provider Network of America Commercial |
$14.52
|
| Rate for Payer: Provider Network of America Commercial |
$15.25
|
| Rate for Payer: UnitedHealthcare Commercial |
$11.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.58
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$18.15
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$19.06
|
|
|
Dressing Optifoam Sacrum
|
Facility
|
IP
|
$18.15
|
|
|
Service Code
|
CPT A6213
|
| Hospital Charge Code |
Px0272A621302
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.61 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$19.06
|
| Rate for Payer: Cash Price |
$19.06
|
| Rate for Payer: Cash Price |
$18.15
|
| Rate for Payer: Cash Price |
$18.15
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$14.29
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$13.61
|
| Rate for Payer: Provider Network of America Commercial |
$14.52
|
| Rate for Payer: Provider Network of America Commercial |
$15.25
|
|
|
Dressing Optilock 5x5.5
|
Facility
|
OP
|
$81.08
|
|
|
Service Code
|
CPT A6197
|
| Hospital Charge Code |
Px0270A619703
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$46.22 |
| Max. Negotiated Rate |
$81.08 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$57.16
|
| Rate for Payer: Aetna Workers' Compensation |
$57.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$56.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$56.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$63.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$63.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$63.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$62.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$63.89
|
| Rate for Payer: Cash Price |
$81.08
|
| Rate for Payer: Cigna Commercial |
$49.62
|
| Rate for Payer: Cigna Medicare Advantage |
$46.22
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$51.08
|
| Rate for Payer: Home State Health Plan Exchange |
$46.22
|
| Rate for Payer: Humana Medicare |
$60.81
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$60.81
|
| Rate for Payer: Provider Network of America Commercial |
$64.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$53.51
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$81.08
|
|
|
Dressing Optilock 5x5.5
|
Facility
|
IP
|
$81.08
|
|
|
Service Code
|
CPT A6197
|
| Hospital Charge Code |
Px0270A619703
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$60.81 |
| 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 |
$81.08
|
| Rate for Payer: Cash Price |
$81.08
|
| 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 |
$60.81
|
| Rate for Payer: Provider Network of America Commercial |
$64.86
|
|
|
droNABinol 2.5 mg capsule 100 Each BLIST PACK
|
Facility
|
OP
|
$33.98
|
|
|
Service Code
|
NDC 00904714461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.37 |
| Max. Negotiated Rate |
$33.98 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$23.96
|
| Rate for Payer: Aetna Workers' Compensation |
$23.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$23.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$23.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$26.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$26.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$26.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$26.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$26.78
|
| Rate for Payer: Cash Price |
$33.98
|
| Rate for Payer: Cigna Commercial |
$20.80
|
| Rate for Payer: Cigna Medicare Advantage |
$19.37
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$21.41
|
| Rate for Payer: Home State Health Plan Exchange |
$19.37
|
| Rate for Payer: Humana Medicare |
$25.48
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$25.48
|
| Rate for Payer: Provider Network of America Commercial |
$27.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$22.43
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$33.98
|
|
|
droNABinol 2.5 mg capsule 100 Each BLIST PACK
|
Facility
|
IP
|
$33.98
|
|
|
Service Code
|
NDC 00904714461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.48 |
| 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 |
$33.98
|
| Rate for Payer: Cash Price |
$33.98
|
| 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 |
$25.48
|
| Rate for Payer: Provider Network of America Commercial |
$27.18
|
|
|
droNABinol 2.5 mg capsule 100 Each BLIST PACK
|
Facility
|
OP
|
$33.98
|
|
|
Service Code
|
HCPCS Q0167
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.37 |
| Max. Negotiated Rate |
$33.98 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$23.96
|
| Rate for Payer: Aetna Workers' Compensation |
$23.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$23.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$23.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$26.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$26.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$26.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$26.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$26.78
|
| Rate for Payer: Cash Price |
$33.98
|
| Rate for Payer: Cigna Commercial |
$20.80
|
| Rate for Payer: Cigna Medicare Advantage |
$19.37
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$21.41
|
| Rate for Payer: Home State Health Plan Exchange |
$19.37
|
| Rate for Payer: Humana Medicare |
$25.48
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$25.48
|
| Rate for Payer: Provider Network of America Commercial |
$27.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$22.43
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$33.98
|
|
|
droNABinol 2.5 mg capsule 100 Each BLIST PACK
|
Facility
|
IP
|
$33.98
|
|
|
Service Code
|
HCPCS Q0167
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.48 |
| 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 |
$33.98
|
| Rate for Payer: Cash Price |
$33.98
|
| 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 |
$25.48
|
| Rate for Payer: Provider Network of America Commercial |
$27.18
|
|
|
droPERidol 2.5 mg/mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00517970201
|
|
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
|
|
