|
epoetin alfa-epbx 10,000 unit/mL solution 1 mL Vial
|
Facility
|
IP
|
$452.05
|
|
|
Service Code
|
HCPCS Q5106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$339.04 |
| 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 |
$452.05
|
| Rate for Payer: Cash Price |
$452.05
|
| 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 |
$339.04
|
| Rate for Payer: Provider Network of America Commercial |
$361.64
|
|
|
epoetin alfa-epbx 10,000 unit/mL solution 1 mL Vial
|
Facility
|
OP
|
$452.05
|
|
|
Service Code
|
HCPCS Q5106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$257.67 |
| Max. Negotiated Rate |
$452.05 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$318.70
|
| Rate for Payer: Aetna Workers' Compensation |
$318.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$313.27
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$313.27
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$356.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$356.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$356.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$348.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$356.22
|
| Rate for Payer: Cash Price |
$452.05
|
| Rate for Payer: Cigna Commercial |
$276.65
|
| Rate for Payer: Cigna Medicare Advantage |
$257.67
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$284.79
|
| Rate for Payer: Home State Health Plan Exchange |
$257.67
|
| Rate for Payer: Humana Medicare |
$339.04
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$339.04
|
| Rate for Payer: Provider Network of America Commercial |
$361.64
|
| Rate for Payer: UnitedHealthcare Commercial |
$298.35
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$452.05
|
|
|
epoetin alfa-epbx 10,000 unit/mL solution 1 mL Vial
|
Facility
|
OP
|
$452.05
|
|
|
Service Code
|
NDC 00069130810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$257.67 |
| Max. Negotiated Rate |
$452.05 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$318.70
|
| Rate for Payer: Aetna Workers' Compensation |
$318.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$313.27
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$313.27
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$356.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$356.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$356.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$348.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$356.22
|
| Rate for Payer: Cash Price |
$452.05
|
| Rate for Payer: Cigna Commercial |
$276.65
|
| Rate for Payer: Cigna Medicare Advantage |
$257.67
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$284.79
|
| Rate for Payer: Home State Health Plan Exchange |
$257.67
|
| Rate for Payer: Humana Medicare |
$339.04
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$339.04
|
| Rate for Payer: Provider Network of America Commercial |
$361.64
|
| Rate for Payer: UnitedHealthcare Commercial |
$298.35
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$452.05
|
|
|
epoetin alfa-epbx 10,000 unit/mL solution 1 mL Vial
|
Facility
|
IP
|
$452.05
|
|
|
Service Code
|
NDC 00069130810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$339.04 |
| 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 |
$452.05
|
| Rate for Payer: Cash Price |
$452.05
|
| 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 |
$339.04
|
| Rate for Payer: Provider Network of America Commercial |
$361.64
|
|
|
epoetin alfa-epbx 20,000 unit/mL solution 1 mL Vial
|
Facility
|
OP
|
$904.11
|
|
|
Service Code
|
NDC 00069131110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$515.34 |
| Max. Negotiated Rate |
$904.11 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$637.40
|
| Rate for Payer: Aetna Workers' Compensation |
$637.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$626.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$626.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$712.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$712.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$712.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$696.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$712.44
|
| Rate for Payer: Cash Price |
$904.11
|
| Rate for Payer: Cigna Commercial |
$553.32
|
| Rate for Payer: Cigna Medicare Advantage |
$515.34
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$569.59
|
| Rate for Payer: Home State Health Plan Exchange |
$515.34
|
| Rate for Payer: Humana Medicare |
$678.08
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$678.08
|
| Rate for Payer: Provider Network of America Commercial |
$723.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$596.71
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$904.11
|
|
|
epoetin alfa-epbx 20,000 unit/mL solution 1 mL Vial
|
Facility
|
OP
|
$904.11
|
|
|
Service Code
|
HCPCS Q5106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$515.34 |
| Max. Negotiated Rate |
$904.11 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$637.40
|
| Rate for Payer: Aetna Workers' Compensation |
$637.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$626.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$626.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$712.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$712.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$712.44
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$696.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$712.44
|
| Rate for Payer: Cash Price |
$904.11
|
| Rate for Payer: Cigna Commercial |
$553.32
|
| Rate for Payer: Cigna Medicare Advantage |
$515.34
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$569.59
|
| Rate for Payer: Home State Health Plan Exchange |
$515.34
|
| Rate for Payer: Humana Medicare |
$678.08
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$678.08
|
| Rate for Payer: Provider Network of America Commercial |
$723.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$596.71
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$904.11
|
|
|
epoetin alfa-epbx 20,000 unit/mL solution 1 mL Vial
|
Facility
|
IP
|
$904.11
|
|
|
Service Code
|
NDC 00069131110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$678.08 |
| 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 |
$904.11
|
| Rate for Payer: Cash Price |
$904.11
|
| 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 |
$678.08
|
| Rate for Payer: Provider Network of America Commercial |
$723.29
|
|
|
epoetin alfa-epbx 20,000 unit/mL solution 1 mL Vial
|
Facility
|
IP
|
$904.11
|
|
|
Service Code
|
HCPCS Q5106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$678.08 |
| 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 |
$904.11
|
| Rate for Payer: Cash Price |
$904.11
|
| 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 |
$678.08
|
| Rate for Payer: Provider Network of America Commercial |
$723.29
|
|
|
epoetin alfa-epbx 40,000 unit/mL solution 1 mL Vial
|
Facility
|
IP
|
$1,808.21
|
|
|
Service Code
|
HCPCS Q5106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$1,808.21
|
| Rate for Payer: Cash Price |
$1,808.21
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,356.16
|
| Rate for Payer: Provider Network of America Commercial |
$1,446.57
|
|
|
epoetin alfa-epbx 40,000 unit/mL solution 1 mL Vial
|
Facility
|
OP
|
$1,808.21
|
|
|
Service Code
|
HCPCS Q5106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,030.68 |
| Max. Negotiated Rate |
$1,808.21 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,274.79
|
| Rate for Payer: Aetna Workers' Compensation |
$1,274.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,253.09
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,253.09
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,424.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,424.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,424.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$1,392.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,424.87
|
| Rate for Payer: Cash Price |
$1,808.21
|
| Rate for Payer: Cigna Commercial |
$1,106.62
|
| Rate for Payer: Cigna Medicare Advantage |
$1,030.68
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,139.17
|
| Rate for Payer: Home State Health Plan Exchange |
$1,030.68
|
| Rate for Payer: Humana Medicare |
$1,356.16
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,356.16
|
| Rate for Payer: Provider Network of America Commercial |
$1,446.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,193.42
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,808.21
|
|
|
epoetin alfa-epbx 40,000 unit/mL solution 1 mL Vial
|
Facility
|
IP
|
$1,808.21
|
|
|
Service Code
|
NDC 00069130904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$1,808.21
|
| Rate for Payer: Cash Price |
$1,808.21
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,356.16
|
| Rate for Payer: Provider Network of America Commercial |
$1,446.57
|
|
|
epoetin alfa-epbx 40,000 unit/mL solution 1 mL Vial
|
Facility
|
OP
|
$1,808.21
|
|
|
Service Code
|
NDC 00069130904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,030.68 |
| Max. Negotiated Rate |
$1,808.21 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,274.79
|
| Rate for Payer: Aetna Workers' Compensation |
$1,274.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,253.09
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,253.09
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,424.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,424.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,424.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$1,392.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,424.87
|
| Rate for Payer: Cash Price |
$1,808.21
|
| Rate for Payer: Cigna Commercial |
$1,106.62
|
| Rate for Payer: Cigna Medicare Advantage |
$1,030.68
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,139.17
|
| Rate for Payer: Home State Health Plan Exchange |
$1,030.68
|
| Rate for Payer: Humana Medicare |
$1,356.16
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,356.16
|
| Rate for Payer: Provider Network of America Commercial |
$1,446.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,193.42
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,808.21
|
|
|
Epoetin Alfa, Non-Esrd
|
Facility
|
IP
|
$1,714.72
|
|
|
Service Code
|
CPT J0885
|
| Hospital Charge Code |
Px0636J088501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$1,714.72
|
| Rate for Payer: Cash Price |
$1,714.72
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,286.04
|
| Rate for Payer: Provider Network of America Commercial |
$1,371.78
|
|
|
Epoetin Alfa, Non-Esrd
|
Facility
|
OP
|
$1,714.72
|
|
|
Service Code
|
CPT J0885
|
| Hospital Charge Code |
Px0636J088501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$977.39 |
| Max. Negotiated Rate |
$1,714.72 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,208.88
|
| Rate for Payer: Aetna Workers' Compensation |
$1,208.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,188.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,188.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,351.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,351.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,351.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$1,320.33
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,351.20
|
| Rate for Payer: Cash Price |
$1,714.72
|
| Rate for Payer: Cigna Commercial |
$1,049.41
|
| Rate for Payer: Cigna Medicare Advantage |
$977.39
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,080.27
|
| Rate for Payer: Home State Health Plan Exchange |
$977.39
|
| Rate for Payer: Humana Medicare |
$1,286.04
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,286.04
|
| Rate for Payer: Provider Network of America Commercial |
$1,371.78
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,131.72
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,714.72
|
|
|
Eptifibatide injection
|
Facility
|
IP
|
$2,070.75
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
Px0636J132701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$2,070.75
|
| Rate for Payer: Cash Price |
$2,070.75
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,553.06
|
| Rate for Payer: Provider Network of America Commercial |
$1,656.60
|
|
|
Eptifibatide injection
|
Facility
|
OP
|
$2,070.75
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
Px0636J132701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,180.33 |
| Max. Negotiated Rate |
$2,070.75 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,459.88
|
| Rate for Payer: Aetna Workers' Compensation |
$1,459.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,435.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,435.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,631.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,631.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,631.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$1,594.48
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,631.75
|
| Rate for Payer: Cash Price |
$2,070.75
|
| Rate for Payer: Cigna Commercial |
$1,267.30
|
| Rate for Payer: Cigna Medicare Advantage |
$1,180.33
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,304.57
|
| Rate for Payer: Home State Health Plan Exchange |
$1,180.33
|
| Rate for Payer: Humana Medicare |
$1,553.06
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,553.06
|
| Rate for Payer: Provider Network of America Commercial |
$1,656.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,366.69
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$2,070.75
|
|
|
eptinezumab-jjmr 100 mg/mL solution 1 mL Vial
|
Facility
|
OP
|
$8,016.36
|
|
|
Service Code
|
HCPCS J3032
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,569.33 |
| Max. Negotiated Rate |
$8,016.36 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5,651.53
|
| Rate for Payer: Aetna Workers' Compensation |
$5,651.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5,555.34
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5,555.34
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$6,316.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$6,316.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$6,316.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$6,172.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$6,316.89
|
| Rate for Payer: Cash Price |
$8,016.36
|
| Rate for Payer: Cigna Commercial |
$4,906.01
|
| Rate for Payer: Cigna Medicare Advantage |
$4,569.33
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$5,050.31
|
| Rate for Payer: Home State Health Plan Exchange |
$4,569.33
|
| Rate for Payer: Humana Medicare |
$6,012.27
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$6,012.27
|
| Rate for Payer: Provider Network of America Commercial |
$6,413.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,290.80
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$8,016.36
|
|
|
eptinezumab-jjmr 100 mg/mL solution 1 mL Vial
|
Facility
|
IP
|
$8,016.36
|
|
|
Service Code
|
HCPCS J3032
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,413.09 |
| 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 |
$8,016.36
|
| Rate for Payer: Cash Price |
$8,016.36
|
| 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 |
$6,012.27
|
| Rate for Payer: Provider Network of America Commercial |
$6,413.09
|
|
|
eptinezumab-jjmr 100 mg/mL solution 1 mL Vial
|
Facility
|
OP
|
$8,016.36
|
|
|
Service Code
|
NDC 67386013051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,569.33 |
| Max. Negotiated Rate |
$8,016.36 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5,651.53
|
| Rate for Payer: Aetna Workers' Compensation |
$5,651.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5,555.34
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5,555.34
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$6,316.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$6,316.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$6,316.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$6,172.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$6,316.89
|
| Rate for Payer: Cash Price |
$8,016.36
|
| Rate for Payer: Cigna Commercial |
$4,906.01
|
| Rate for Payer: Cigna Medicare Advantage |
$4,569.33
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$5,050.31
|
| Rate for Payer: Home State Health Plan Exchange |
$4,569.33
|
| Rate for Payer: Humana Medicare |
$6,012.27
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$6,012.27
|
| Rate for Payer: Provider Network of America Commercial |
$6,413.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,290.80
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$8,016.36
|
|
|
eptinezumab-jjmr 100 mg/mL solution 1 mL Vial
|
Facility
|
IP
|
$8,016.36
|
|
|
Service Code
|
NDC 67386013051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,413.09 |
| 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 |
$8,016.36
|
| Rate for Payer: Cash Price |
$8,016.36
|
| 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 |
$6,012.27
|
| Rate for Payer: Provider Network of America Commercial |
$6,413.09
|
|
|
eravacycline 50 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$291.67
|
|
|
Service Code
|
NDC 71773005001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$166.25 |
| Max. Negotiated Rate |
$291.67 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$205.63
|
| Rate for Payer: Aetna Workers' Compensation |
$205.63
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$202.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$202.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$229.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$229.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$229.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$224.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$229.84
|
| Rate for Payer: Cash Price |
$291.67
|
| Rate for Payer: Cigna Commercial |
$178.50
|
| Rate for Payer: Cigna Medicare Advantage |
$166.25
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$183.75
|
| Rate for Payer: Home State Health Plan Exchange |
$166.25
|
| Rate for Payer: Humana Medicare |
$218.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$218.75
|
| Rate for Payer: Provider Network of America Commercial |
$233.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$192.50
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$291.67
|
|
|
eravacycline 50 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$291.67
|
|
|
Service Code
|
NDC 71773005012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$218.75 |
| 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 |
$291.67
|
| Rate for Payer: Cash Price |
$291.67
|
| 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 |
$218.75
|
| Rate for Payer: Provider Network of America Commercial |
$233.34
|
|
|
eravacycline 50 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$291.67
|
|
|
Service Code
|
NDC 71773005012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$166.25 |
| Max. Negotiated Rate |
$291.67 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$205.63
|
| Rate for Payer: Aetna Workers' Compensation |
$205.63
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$202.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$202.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$229.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$229.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$229.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$224.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$229.84
|
| Rate for Payer: Cash Price |
$291.67
|
| Rate for Payer: Cigna Commercial |
$178.50
|
| Rate for Payer: Cigna Medicare Advantage |
$166.25
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$183.75
|
| Rate for Payer: Home State Health Plan Exchange |
$166.25
|
| Rate for Payer: Humana Medicare |
$218.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$218.75
|
| Rate for Payer: Provider Network of America Commercial |
$233.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$192.50
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$291.67
|
|
|
eravacycline 50 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$291.67
|
|
|
Service Code
|
HCPCS J0122
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$218.75 |
| 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 |
$291.67
|
| Rate for Payer: Cash Price |
$291.67
|
| 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 |
$218.75
|
| Rate for Payer: Provider Network of America Commercial |
$233.34
|
|
|
eravacycline 50 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$291.67
|
|
|
Service Code
|
HCPCS J0122
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$166.25 |
| Max. Negotiated Rate |
$291.67 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$205.63
|
| Rate for Payer: Aetna Workers' Compensation |
$205.63
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$202.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$202.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$229.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$229.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$229.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$224.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$229.84
|
| Rate for Payer: Cash Price |
$291.67
|
| Rate for Payer: Cigna Commercial |
$178.50
|
| Rate for Payer: Cigna Medicare Advantage |
$166.25
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$183.75
|
| Rate for Payer: Home State Health Plan Exchange |
$166.25
|
| Rate for Payer: Humana Medicare |
$218.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$218.75
|
| Rate for Payer: Provider Network of America Commercial |
$233.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$192.50
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$291.67
|
|
