|
estradiol 1 mg tablet 100 Each Bottle
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00555088602
|
|
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
|
|
|
estradiol 1 mg tablet 100 Each Bottle
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 70954056510
|
|
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
|
|
|
estradiol 1 mg tablet 100 Each Bottle
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 70954056510
|
|
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
|
|
|
estradiol 1 mg tablet 100 Each Bottle
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00555088602
|
|
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
|
|
|
estrogens (conjugated) 0.625 mg/gram cream 30 g TUBE/KIT
|
Facility
|
OP
|
$1,893.16
|
|
|
Service Code
|
NDC 00046087221
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,079.10 |
| Max. Negotiated Rate |
$1,893.16 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,334.68
|
| Rate for Payer: Aetna Workers' Compensation |
$1,334.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,311.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,311.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,491.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,491.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,491.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$1,457.73
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,491.81
|
| Rate for Payer: Cash Price |
$1,893.16
|
| Rate for Payer: Cigna Commercial |
$1,158.61
|
| Rate for Payer: Cigna Medicare Advantage |
$1,079.10
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,192.69
|
| Rate for Payer: Home State Health Plan Exchange |
$1,079.10
|
| Rate for Payer: Humana Medicare |
$1,419.87
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,419.87
|
| Rate for Payer: Provider Network of America Commercial |
$1,514.53
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,249.49
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,893.16
|
|
|
estrogens (conjugated) 0.625 mg/gram cream 30 g TUBE/KIT
|
Facility
|
IP
|
$1,893.16
|
|
|
Service Code
|
NDC 00046087221
|
|
Hospital Revenue Code
|
637
|
| 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 |
$1,893.16
|
| Rate for Payer: Cash Price |
$1,893.16
|
| 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 |
$1,419.87
|
| Rate for Payer: Provider Network of America Commercial |
$1,514.53
|
|
|
ethyl chloride 100 % aerosol,spray 116 mL SQUEEZ BTL
|
Facility
|
IP
|
$136.48
|
|
|
Service Code
|
NDC 00386000111
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.36 |
| 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 |
$136.48
|
| Rate for Payer: Cash Price |
$136.48
|
| 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 |
$102.36
|
| Rate for Payer: Provider Network of America Commercial |
$109.18
|
|
|
ethyl chloride 100 % aerosol,spray 116 mL SQUEEZ BTL
|
Facility
|
OP
|
$136.48
|
|
|
Service Code
|
NDC 00386000111
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.79 |
| Max. Negotiated Rate |
$136.48 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$96.22
|
| Rate for Payer: Aetna Workers' Compensation |
$96.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$94.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$94.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$107.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$107.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$107.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$105.09
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$107.55
|
| Rate for Payer: Cash Price |
$136.48
|
| Rate for Payer: Cigna Commercial |
$83.53
|
| Rate for Payer: Cigna Medicare Advantage |
$77.79
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$85.98
|
| Rate for Payer: Home State Health Plan Exchange |
$77.79
|
| Rate for Payer: Humana Medicare |
$102.36
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$102.36
|
| Rate for Payer: Provider Network of America Commercial |
$109.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$90.08
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$136.48
|
|
|
etomidate 2 mg/mL solution 20 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00143950701
|
|
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
|
|
|
etomidate 2 mg/mL solution 20 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00143950701
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
etonogestrel 68 mg implant 1 Each PF APPLI
|
Facility
|
IP
|
$5,101.44
|
|
|
Service Code
|
HCPCS J7307
|
|
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 |
$5,101.44
|
| Rate for Payer: Cash Price |
$5,101.44
|
| 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 |
$3,826.08
|
| Rate for Payer: Provider Network of America Commercial |
$4,081.15
|
|
|
etonogestrel 68 mg implant 1 Each PF APPLI
|
Facility
|
IP
|
$5,101.44
|
|
|
Service Code
|
NDC 78206014501
|
|
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 |
$5,101.44
|
| Rate for Payer: Cash Price |
$5,101.44
|
| 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 |
$3,826.08
|
| Rate for Payer: Provider Network of America Commercial |
$4,081.15
|
|
|
etonogestrel 68 mg implant 1 Each PF APPLI
|
Facility
|
OP
|
$5,101.44
|
|
|
Service Code
|
HCPCS J7307
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,907.82 |
| Max. Negotiated Rate |
$5,101.44 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$3,596.52
|
| Rate for Payer: Aetna Workers' Compensation |
$3,596.52
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$3,535.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$3,535.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$4,019.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$4,019.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$4,019.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3,928.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$4,019.93
|
| Rate for Payer: Cash Price |
$5,101.44
|
| Rate for Payer: Cigna Commercial |
$3,122.08
|
| Rate for Payer: Cigna Medicare Advantage |
$2,907.82
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$3,213.91
|
| Rate for Payer: Home State Health Plan Exchange |
$2,907.82
|
| Rate for Payer: Humana Medicare |
$3,826.08
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3,826.08
|
| Rate for Payer: Provider Network of America Commercial |
$4,081.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$3,366.95
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$5,101.44
|
|
|
etonogestrel 68 mg implant 1 Each PF APPLI
|
Facility
|
OP
|
$5,101.44
|
|
|
Service Code
|
NDC 78206014501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,907.82 |
| Max. Negotiated Rate |
$5,101.44 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$3,596.52
|
| Rate for Payer: Aetna Workers' Compensation |
$3,596.52
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$3,535.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$3,535.30
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$4,019.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$4,019.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$4,019.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3,928.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$4,019.93
|
| Rate for Payer: Cash Price |
$5,101.44
|
| Rate for Payer: Cigna Commercial |
$3,122.08
|
| Rate for Payer: Cigna Medicare Advantage |
$2,907.82
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$3,213.91
|
| Rate for Payer: Home State Health Plan Exchange |
$2,907.82
|
| Rate for Payer: Humana Medicare |
$3,826.08
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3,826.08
|
| Rate for Payer: Provider Network of America Commercial |
$4,081.15
|
| Rate for Payer: UnitedHealthcare Commercial |
$3,366.95
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$5,101.44
|
|
|
Etonogestrel implant system
|
Facility
|
IP
|
$2,428.19
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
Px0636J730701
|
|
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 |
$2,428.19
|
| Rate for Payer: Cash Price |
$2,428.19
|
| 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 |
$1,821.14
|
| Rate for Payer: Provider Network of America Commercial |
$1,942.55
|
|
|
Etonogestrel implant system
|
Facility
|
OP
|
$2,428.19
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
Px0636J730701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,384.07 |
| Max. Negotiated Rate |
$2,428.19 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,711.87
|
| Rate for Payer: Aetna Workers' Compensation |
$1,711.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,682.74
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,682.74
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,913.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,913.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,913.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$1,869.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,913.41
|
| Rate for Payer: Cash Price |
$2,428.19
|
| Rate for Payer: Cigna Commercial |
$1,486.05
|
| Rate for Payer: Cigna Medicare Advantage |
$1,384.07
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,529.76
|
| Rate for Payer: Home State Health Plan Exchange |
$1,384.07
|
| Rate for Payer: Humana Medicare |
$1,821.14
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,821.14
|
| Rate for Payer: Provider Network of America Commercial |
$1,942.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,602.61
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$2,428.19
|
|
|
Etoposide injection
|
Facility
|
IP
|
$13.26
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
Px0636J918101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.95 |
| 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 |
$13.26
|
| Rate for Payer: Cash Price |
$13.26
|
| 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 |
$9.95
|
| Rate for Payer: Provider Network of America Commercial |
$10.61
|
|
|
Etoposide injection
|
Facility
|
OP
|
$13.26
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
Px0636J918101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$13.26 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$9.35
|
| Rate for Payer: Aetna Workers' Compensation |
$9.35
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$9.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$9.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$10.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$10.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$10.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$10.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$10.45
|
| Rate for Payer: Cash Price |
$13.26
|
| Rate for Payer: Cigna Commercial |
$8.12
|
| Rate for Payer: Cigna Medicare Advantage |
$7.56
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$8.35
|
| Rate for Payer: Home State Health Plan Exchange |
$7.56
|
| Rate for Payer: Humana Medicare |
$9.95
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$9.95
|
| Rate for Payer: Provider Network of America Commercial |
$10.61
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.75
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$13.26
|
|
|
etoposide per 10 mg
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
NDC 00143951001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.05 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$45.83
|
| Rate for Payer: Aetna Workers' Compensation |
$45.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$45.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$45.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$51.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$51.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$51.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$50.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$51.22
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$39.78
|
| Rate for Payer: Cigna Medicare Advantage |
$37.05
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$40.95
|
| Rate for Payer: Home State Health Plan Exchange |
$37.05
|
| Rate for Payer: Humana Medicare |
$48.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$48.75
|
| Rate for Payer: Provider Network of America Commercial |
$52.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$42.90
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$65.00
|
|
|
etoposide per 10 mg
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
NDC 00143951001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.75 |
| 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 |
$65.00
|
| Rate for Payer: Cash Price |
$65.00
|
| 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 |
$48.75
|
| Rate for Payer: Provider Network of America Commercial |
$52.00
|
|
|
etoposide per 10 mg
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS J9181
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.75 |
| 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 |
$65.00
|
| Rate for Payer: Cash Price |
$65.00
|
| 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 |
$48.75
|
| Rate for Payer: Provider Network of America Commercial |
$52.00
|
|
|
etoposide per 10 mg
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS J9181
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.05 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$45.83
|
| Rate for Payer: Aetna Workers' Compensation |
$45.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$45.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$45.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$51.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$51.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$51.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$50.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$51.22
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$39.78
|
| Rate for Payer: Cigna Medicare Advantage |
$37.05
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$40.95
|
| Rate for Payer: Home State Health Plan Exchange |
$37.05
|
| Rate for Payer: Humana Medicare |
$48.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$48.75
|
| Rate for Payer: Provider Network of America Commercial |
$52.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$42.90
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$65.00
|
|
|
Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 1.1-2.0cm
|
Professional
|
Both
|
$3,311.00
|
|
|
Service Code
|
CPT 11422
|
| Hospital Charge Code |
Px00000011422
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$144.31 |
| Max. Negotiated Rate |
$144.31 |
| Rate for Payer: Cash Price |
$3,311.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$144.31
|
|
|
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 1.1-2.0 Cm
|
Professional
|
Both
|
$1,395.00
|
|
|
Service Code
|
CPT 11402
|
| Hospital Charge Code |
Px00000011402
|
|
Hospital Revenue Code
|
490
|
| Min. Negotiated Rate |
$119.45 |
| Max. Negotiated Rate |
$119.45 |
| Rate for Payer: Cash Price |
$1,395.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$119.45
|
|
|
Exc B9 Lesion Mrgn Xcp Sk Tg T/a/L 2.1-3.0 Cm
|
Facility
|
OP
|
$2,005.50
|
|
|
Service Code
|
CPT 11403
|
| Hospital Charge Code |
Px05101140301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$672.81 |
| Max. Negotiated Rate |
$2,005.50 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,413.88
|
| Rate for Payer: Aetna Workers' Compensation |
$1,413.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,389.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,389.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,580.33
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,580.33
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,580.33
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$1,544.23
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,580.33
|
| Rate for Payer: Cash Price |
$2,005.50
|
| Rate for Payer: Cash Price |
$2,005.50
|
| Rate for Payer: Cigna Medicare Advantage |
$1,143.13
|
| Rate for Payer: Family Health Partners Medicaid |
$893.68
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,263.46
|
| Rate for Payer: Healthy Blue Medicaid |
$965.17
|
| Rate for Payer: Home State Health Plan Exchange |
$1,143.13
|
| Rate for Payer: Home State Health Plan Medicaid |
$893.68
|
| Rate for Payer: Humana Medicare |
$1,504.12
|
| Rate for Payer: Mercy CarePlus Medicaid |
$893.68
|
| Rate for Payer: Provider Network of America Commercial |
$1,604.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,323.63
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$2,005.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$672.81
|
|
