|
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
|
|
|
ertapenem 1 gram recon soln 1 Each Vial
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
NDC 60505619600
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.40 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$84.60
|
| Rate for Payer: Aetna Workers' Compensation |
$84.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$92.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$94.56
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$73.44
|
| Rate for Payer: Cigna Medicare Advantage |
$68.40
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$75.60
|
| Rate for Payer: Home State Health Plan Exchange |
$68.40
|
| Rate for Payer: Humana Medicare |
$90.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$90.00
|
| Rate for Payer: Provider Network of America Commercial |
$96.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$79.20
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$120.00
|
|
|
ertapenem 1 gram recon soln 1 Each Vial
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
NDC 60505619600
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.00 |
| 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 |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| 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 |
$90.00
|
| Rate for Payer: Provider Network of America Commercial |
$96.00
|
|
|
ertapenem 1 gram recon soln 1 Each Vial
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
NDC 55150028220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.00 |
| 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 |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| 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 |
$90.00
|
| Rate for Payer: Provider Network of America Commercial |
$96.00
|
|
|
ertapenem 1 gram recon soln 1 Each Vial
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
NDC 43598090111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$228.00 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$282.00
|
| Rate for Payer: Aetna Workers' Compensation |
$282.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$277.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$277.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$315.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$315.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$315.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$308.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$315.20
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$244.80
|
| Rate for Payer: Cigna Medicare Advantage |
$228.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$252.00
|
| Rate for Payer: Home State Health Plan Exchange |
$228.00
|
| Rate for Payer: Humana Medicare |
$300.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$300.00
|
| Rate for Payer: Provider Network of America Commercial |
$320.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$264.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$400.00
|
|
|
ertapenem 1 gram recon soln 1 Each Vial
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
NDC 43598090111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$300.00 |
| 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 |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| 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 |
$300.00
|
| Rate for Payer: Provider Network of America Commercial |
$320.00
|
|
|
ertapenem 1 gram recon soln 1 Each Vial
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.40 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$84.60
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$282.00
|
| Rate for Payer: Aetna Workers' Compensation |
$84.60
|
| Rate for Payer: Aetna Workers' Compensation |
$282.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$277.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$277.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$315.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$315.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$315.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$92.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$308.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$315.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$94.56
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$73.44
|
| Rate for Payer: Cigna Commercial |
$244.80
|
| Rate for Payer: Cigna Medicare Advantage |
$68.40
|
| Rate for Payer: Cigna Medicare Advantage |
$228.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$75.60
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$252.00
|
| Rate for Payer: Home State Health Plan Exchange |
$68.40
|
| Rate for Payer: Home State Health Plan Exchange |
$228.00
|
| Rate for Payer: Humana Medicare |
$90.00
|
| Rate for Payer: Humana Medicare |
$300.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$90.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$300.00
|
| Rate for Payer: Provider Network of America Commercial |
$96.00
|
| Rate for Payer: Provider Network of America Commercial |
$320.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$79.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$264.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$120.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$400.00
|
|
|
ertapenem 1 gram recon soln 1 Each Vial
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
NDC 55150028220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.40 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$84.60
|
| Rate for Payer: Aetna Workers' Compensation |
$84.60
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$83.16
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$94.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$92.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$94.56
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$73.44
|
| Rate for Payer: Cigna Medicare Advantage |
$68.40
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$75.60
|
| Rate for Payer: Home State Health Plan Exchange |
$68.40
|
| Rate for Payer: Humana Medicare |
$90.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$90.00
|
| Rate for Payer: Provider Network of America Commercial |
$96.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$79.20
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$120.00
|
|
|
ertapenem 1 gram recon soln 1 Each Vial
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.00 |
| 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 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 |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| 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 |
$300.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$90.00
|
| Rate for Payer: Provider Network of America Commercial |
$96.00
|
| Rate for Payer: Provider Network of America Commercial |
$320.00
|
|
|
Ertapenem injection
|
Facility
|
IP
|
$74.22
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
Px0636J133501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.66 |
| 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 |
$74.22
|
| Rate for Payer: Cash Price |
$74.22
|
| 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 |
$55.66
|
| Rate for Payer: Provider Network of America Commercial |
$59.38
|
|
|
Ertapenem injection
|
Facility
|
OP
|
$74.22
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
Px0636J133501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.31 |
| Max. Negotiated Rate |
$74.22 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$52.33
|
| Rate for Payer: Aetna Workers' Compensation |
$52.33
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$51.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$51.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$58.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$58.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$58.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$57.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$58.49
|
| Rate for Payer: Cash Price |
$74.22
|
| Rate for Payer: Cigna Commercial |
$45.42
|
| Rate for Payer: Cigna Medicare Advantage |
$42.31
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$46.76
|
| Rate for Payer: Home State Health Plan Exchange |
$42.31
|
| Rate for Payer: Humana Medicare |
$55.66
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$55.66
|
| Rate for Payer: Provider Network of America Commercial |
$59.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$48.99
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$74.22
|
|
|
erythromycin 5 mg/gram (0.5 %) ointment 3.5 g Tube
|
Facility
|
IP
|
$60.80
|
|
|
Service Code
|
NDC 24208091055
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.60 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$60.80
|
| Rate for Payer: Cash Price |
$60.80
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$45.60
|
| Rate for Payer: Provider Network of America Commercial |
$48.64
|
|
|
erythromycin 5 mg/gram (0.5 %) ointment 3.5 g Tube
|
Facility
|
OP
|
$60.80
|
|
|
Service Code
|
NDC 24208091055
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.66 |
| Max. Negotiated Rate |
$60.80 |
| Rate for Payer: Humana Medicare |
$45.60
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$42.86
|
| Rate for Payer: Aetna Workers' Compensation |
$42.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$42.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$42.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$47.91
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$47.91
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$47.91
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$46.82
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$47.91
|
| Rate for Payer: Cash Price |
$60.80
|
| Rate for Payer: Cigna Commercial |
$37.21
|
| Rate for Payer: Cigna Medicare Advantage |
$34.66
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$38.30
|
| Rate for Payer: Home State Health Plan Exchange |
$34.66
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$45.60
|
| Rate for Payer: Provider Network of America Commercial |
$48.64
|
| Rate for Payer: UnitedHealthcare Commercial |
$40.13
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$60.80
|
|
|
escitalopram 10 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904642661
|
|
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
|
|
|
escitalopram 10 mg tablet 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904642661
|
|
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
|
|
|
esmolol 10 mg/mL solution 10 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J1805
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
esmolol 10 mg/mL solution 10 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 55150019410
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
esmolol 10 mg/mL solution 10 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 55150019410
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$24.68
|
| Rate for Payer: Aetna Workers' Compensation |
$24.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$26.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$27.58
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Commercial |
$21.42
|
| Rate for Payer: Cigna Medicare Advantage |
$19.95
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$22.05
|
| Rate for Payer: Home State Health Plan Exchange |
$19.95
|
| Rate for Payer: Humana Medicare |
$26.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Provider Network of America Commercial |
$28.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.10
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$35.00
|
|
|
esmolol 10 mg/mL solution 10 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J1805
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$24.68
|
| Rate for Payer: Aetna Workers' Compensation |
$24.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$26.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$27.58
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Commercial |
$21.42
|
| Rate for Payer: Cigna Medicare Advantage |
$19.95
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$22.05
|
| Rate for Payer: Home State Health Plan Exchange |
$19.95
|
| Rate for Payer: Humana Medicare |
$26.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Provider Network of America Commercial |
$28.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.10
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$35.00
|
|
|
ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 391
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$5,961.01
|
|
|
ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 392
|
| 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 Freedom Network |
$3,487.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3,487.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$3,487.00
|
| 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 Traditional |
$3,487.00
|
| 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 |
$3,664.12
|
|
|
Esophagoscopy Flexible Transoral Diagnostic - Esophagoscopy
|
Facility
|
OP
|
$1,890.00
|
|
|
Service Code
|
CPT 43200
|
| Hospital Charge Code |
Px07504320001
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$861.75 |
| Max. Negotiated Rate |
$1,890.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,309.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,309.77
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,489.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,489.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,489.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$1,455.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,489.32
|
| Rate for Payer: Cash Price |
$1,890.00
|
| Rate for Payer: Cash Price |
$1,890.00
|
| Rate for Payer: Cigna Commercial |
$1,253.07
|
| Rate for Payer: Cigna Medicare Advantage |
$1,077.30
|
| Rate for Payer: Family Health Partners Medicaid |
$1,144.64
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,190.70
|
| Rate for Payer: Healthy Blue Medicaid |
$1,236.21
|
| Rate for Payer: Home State Health Plan Exchange |
$1,077.30
|
| Rate for Payer: Home State Health Plan Medicaid |
$1,144.64
|
| Rate for Payer: Humana Medicare |
$1,417.50
|
| Rate for Payer: Mercy CarePlus Medicaid |
$1,144.64
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,417.50
|
| Rate for Payer: Provider Network of America Commercial |
$1,512.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,247.40
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,890.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$861.75
|
|
|
Esophagoscopy Flexible Transoral Diagnostic - Esophagoscopy
|
Facility
|
IP
|
$1,890.00
|
|
|
Service Code
|
CPT 43200
|
| Hospital Charge Code |
Px07504320001
|
|
Hospital Revenue Code
|
750
|
| 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 |
$1,890.00
|
| Rate for Payer: Cash Price |
$1,890.00
|
| 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 |
$1,417.50
|
| Rate for Payer: Provider Network of America Commercial |
$1,512.00
|
|
|
Established Patient Office or Other Outpatinet Visit
|
Facility
|
IP
|
$65.10
|
|
|
Service Code
|
CPT 99211 25
|
| Hospital Charge Code |
Px07619921102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$48.83 |
| 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 |
$65.10
|
| Rate for Payer: Cash Price |
$65.10
|
| 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 |
$48.83
|
| Rate for Payer: Provider Network of America Commercial |
$52.08
|
|
|
Established Patient Office or Other Outpatinet Visit
|
Facility
|
OP
|
$65.10
|
|
|
Service Code
|
CPT 99211 25
|
| Hospital Charge Code |
Px07619921102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.11 |
| Max. Negotiated Rate |
$65.10 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$45.90
|
| Rate for Payer: Aetna Workers' Compensation |
$45.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$45.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$45.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$51.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$51.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$51.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$50.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$51.30
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Cigna Commercial |
$39.84
|
| Rate for Payer: Cigna Medicare Advantage |
$37.11
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$41.01
|
| Rate for Payer: Home State Health Plan Exchange |
$37.11
|
| Rate for Payer: Humana Medicare |
$48.83
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$48.83
|
| Rate for Payer: Provider Network of America Commercial |
$52.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$42.97
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$65.10
|
|
