|
EYE INFECTIONS AND OTHER EYE DISORDERS
|
Facility
|
IP
|
$6,415.24
|
|
|
Service Code
|
APR-DRG 0821
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,415.24 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$6,415.24
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$6,415.24
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$6,415.24
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$6,415.24
|
|
|
eye wash (boric acid) irrigation solution 118 mL Bottle
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00536122497
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.75 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| 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 |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$33.75
|
| Rate for Payer: Provider Network of America Commercial |
$36.00
|
|
|
eye wash (boric acid) irrigation solution 118 mL Bottle
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00536122497
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.65 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$31.73
|
| Rate for Payer: Aetna Workers' Compensation |
$31.73
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$31.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$31.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$35.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$35.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$35.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$34.65
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$35.46
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$27.54
|
| Rate for Payer: Cigna Medicare Advantage |
$25.65
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$28.35
|
| Rate for Payer: Home State Health Plan Exchange |
$25.65
|
| Rate for Payer: Humana Medicare |
$33.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$33.75
|
| Rate for Payer: Provider Network of America Commercial |
$36.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$29.70
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$45.00
|
|
|
ezetimibe 10 mg tablet 1 Each BLIST PACK
|
Facility
|
OP
|
$19.99
|
|
|
Service Code
|
NDC 50268029811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.39 |
| Max. Negotiated Rate |
$19.99 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$14.09
|
| Rate for Payer: Aetna Workers' Compensation |
$14.09
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$13.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$13.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$15.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$15.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$15.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$15.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$15.75
|
| Rate for Payer: Cash Price |
$19.99
|
| Rate for Payer: Cigna Commercial |
$12.23
|
| Rate for Payer: Cigna Medicare Advantage |
$11.39
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$12.59
|
| Rate for Payer: Home State Health Plan Exchange |
$11.39
|
| Rate for Payer: Humana Medicare |
$14.99
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$14.99
|
| Rate for Payer: Provider Network of America Commercial |
$15.99
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.19
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$19.99
|
|
|
ezetimibe 10 mg tablet 1 Each BLIST PACK
|
Facility
|
IP
|
$19.99
|
|
|
Service Code
|
NDC 50268029811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.99 |
| 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 |
$19.99
|
| Rate for Payer: Cash Price |
$19.99
|
| 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 |
$14.99
|
| Rate for Payer: Provider Network of America Commercial |
$15.99
|
|
|
ezetimibe 10 mg tablet 20 Each BLIST PACK
|
Facility
|
OP
|
$21.30
|
|
|
Service Code
|
NDC 00904710310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.14 |
| Max. Negotiated Rate |
$21.30 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$15.02
|
| Rate for Payer: Aetna Workers' Compensation |
$15.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$14.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$14.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$16.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$16.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$16.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$16.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$16.78
|
| Rate for Payer: Cash Price |
$21.30
|
| Rate for Payer: Cigna Commercial |
$13.04
|
| Rate for Payer: Cigna Medicare Advantage |
$12.14
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$13.42
|
| Rate for Payer: Home State Health Plan Exchange |
$12.14
|
| Rate for Payer: Humana Medicare |
$15.97
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$15.97
|
| Rate for Payer: Provider Network of America Commercial |
$17.04
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.06
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$21.30
|
|
|
ezetimibe 10 mg tablet 20 Each BLIST PACK
|
Facility
|
IP
|
$21.30
|
|
|
Service Code
|
NDC 00904710310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.97 |
| 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 |
$21.30
|
| Rate for Payer: Cash Price |
$21.30
|
| 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 |
$15.97
|
| Rate for Payer: Provider Network of America Commercial |
$17.04
|
|
|
F-18 fludeoxyglucose 20 mCi to 200 mCi/mL solution 1 Each Vial
|
Facility
|
IP
|
$800.00
|
|
|
Service Code
|
HCPCS A9552
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$600.00 |
| 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 |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| 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 |
$600.00
|
| Rate for Payer: Provider Network of America Commercial |
$640.00
|
|
|
F-18 fludeoxyglucose 20 mCi to 200 mCi/mL solution 1 Each Vial
|
Facility
|
OP
|
$800.00
|
|
|
Service Code
|
NDC 40028051150
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$456.00 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$564.00
|
| Rate for Payer: Aetna Workers' Compensation |
$564.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$554.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$554.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$630.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$630.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$630.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$616.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$630.40
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$489.60
|
| Rate for Payer: Cigna Medicare Advantage |
$456.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$504.00
|
| Rate for Payer: Home State Health Plan Exchange |
$456.00
|
| Rate for Payer: Humana Medicare |
$600.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$600.00
|
| Rate for Payer: Provider Network of America Commercial |
$640.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$528.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$800.00
|
|
|
F-18 fludeoxyglucose 20 mCi to 200 mCi/mL solution 1 Each Vial
|
Facility
|
OP
|
$800.00
|
|
|
Service Code
|
HCPCS A9552
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$456.00 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$564.00
|
| Rate for Payer: Aetna Workers' Compensation |
$564.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$554.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$554.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$630.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$630.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$630.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$616.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$630.40
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$489.60
|
| Rate for Payer: Cigna Medicare Advantage |
$456.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$504.00
|
| Rate for Payer: Home State Health Plan Exchange |
$456.00
|
| Rate for Payer: Humana Medicare |
$600.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$600.00
|
| Rate for Payer: Provider Network of America Commercial |
$640.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$528.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$800.00
|
|
|
F-18 fludeoxyglucose 20 mCi to 200 mCi/mL solution 1 Each Vial
|
Facility
|
IP
|
$800.00
|
|
|
Service Code
|
NDC 40028051130
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$600.00 |
| 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 |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| 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 |
$600.00
|
| Rate for Payer: Provider Network of America Commercial |
$640.00
|
|
|
F-18 fludeoxyglucose 20 mCi to 200 mCi/mL solution 1 Each Vial
|
Facility
|
OP
|
$800.00
|
|
|
Service Code
|
NDC 40028051130
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$456.00 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$564.00
|
| Rate for Payer: Aetna Workers' Compensation |
$564.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$554.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$554.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$630.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$630.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$630.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$616.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$630.40
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$489.60
|
| Rate for Payer: Cigna Medicare Advantage |
$456.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$504.00
|
| Rate for Payer: Home State Health Plan Exchange |
$456.00
|
| Rate for Payer: Humana Medicare |
$600.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$600.00
|
| Rate for Payer: Provider Network of America Commercial |
$640.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$528.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$800.00
|
|
|
F-18 fludeoxyglucose 20 mCi to 200 mCi/mL solution 1 Each Vial
|
Facility
|
IP
|
$800.00
|
|
|
Service Code
|
NDC 40028051150
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$600.00 |
| 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 |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| 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 |
$600.00
|
| Rate for Payer: Provider Network of America Commercial |
$640.00
|
|
|
F2 Gene Analysis 20210g >a Variant - Prothrombin G20210a
|
Facility
|
OP
|
$581.70
|
|
|
Service Code
|
CPT 81240
|
| Hospital Charge Code |
Px03008124002
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$62.31 |
| Max. Negotiated Rate |
$465.36 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$410.10
|
| Rate for Payer: Aetna Workers' Compensation |
$410.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$403.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$403.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$458.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$458.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$458.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$447.91
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$458.38
|
| Rate for Payer: Cash Price |
$581.70
|
| Rate for Payer: Cash Price |
$581.70
|
| Rate for Payer: Cigna Commercial |
$304.81
|
| Rate for Payer: Cigna Medicare Advantage |
$331.57
|
| Rate for Payer: Family Health Partners Medicaid |
$82.77
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$366.47
|
| Rate for Payer: Healthy Blue Medicaid |
$89.39
|
| Rate for Payer: Home State Health Plan Exchange |
$331.57
|
| Rate for Payer: Home State Health Plan Medicaid |
$82.77
|
| Rate for Payer: Humana Medicare |
$436.27
|
| Rate for Payer: Mercy CarePlus Medicaid |
$82.77
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$436.27
|
| Rate for Payer: Provider Network of America Commercial |
$465.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$383.92
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$65.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$62.31
|
|
|
F2 Gene Analysis 20210g >a Variant - Prothrombin G20210a
|
Facility
|
IP
|
$581.70
|
|
|
Service Code
|
CPT 81240
|
| Hospital Charge Code |
Px03008124002
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$436.27 |
| 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 |
$581.70
|
| Rate for Payer: Cash Price |
$581.70
|
| 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 |
$436.27
|
| Rate for Payer: Provider Network of America Commercial |
$465.36
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$55,452.65
|
|
|
Service Code
|
APR-DRG 0924
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$55,452.65 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$55,452.65
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$55,452.65
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$55,452.65
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$55,452.65
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$20,656.53
|
|
|
Service Code
|
APR-DRG 0922
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$20,656.53 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$20,656.53
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$20,656.53
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$20,656.53
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$20,656.53
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$16,466.61
|
|
|
Service Code
|
APR-DRG 0921
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$16,466.61 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$16,466.61
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$16,466.61
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$16,466.61
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$16,466.61
|
|
|
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES
|
Facility
|
IP
|
$34,758.22
|
|
|
Service Code
|
APR-DRG 0923
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$34,758.22 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Family Health Partners Medicaid |
$34,758.22
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$34,758.22
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$34,758.22
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$34,758.22
|
|
|
Family Psychotherapy W/O Patient Present 50 Mins
|
Facility
|
IP
|
$845.25
|
|
|
Service Code
|
CPT 90846
|
| Hospital Charge Code |
Px09169084601
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$633.94 |
| 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 |
$845.25
|
| Rate for Payer: Cash Price |
$845.25
|
| 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 |
$633.94
|
| Rate for Payer: Provider Network of America Commercial |
$676.20
|
|
|
Family Psychotherapy W/O Patient Present 50 Mins
|
Facility
|
OP
|
$845.25
|
|
|
Service Code
|
CPT 90846
|
| Hospital Charge Code |
Px09169084601
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$168.64 |
| Max. Negotiated Rate |
$845.25 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$595.90
|
| Rate for Payer: Aetna Workers' Compensation |
$595.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$585.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$585.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$666.06
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$666.06
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$666.06
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$650.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$666.06
|
| Rate for Payer: Cash Price |
$845.25
|
| Rate for Payer: Cash Price |
$845.25
|
| Rate for Payer: Cigna Commercial |
$517.29
|
| Rate for Payer: Cigna Medicare Advantage |
$481.79
|
| Rate for Payer: Family Health Partners Medicaid |
$224.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$532.51
|
| Rate for Payer: Healthy Blue Medicaid |
$241.92
|
| Rate for Payer: Home State Health Plan Exchange |
$481.79
|
| Rate for Payer: Home State Health Plan Medicaid |
$224.00
|
| Rate for Payer: Humana Medicare |
$633.94
|
| Rate for Payer: Mercy CarePlus Medicaid |
$224.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$633.94
|
| Rate for Payer: Provider Network of America Commercial |
$676.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$557.87
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$845.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$168.64
|
|
|
Family Psychotherapy W/Patient Present 50 Mins
|
Facility
|
IP
|
$887.25
|
|
|
Service Code
|
CPT 90847
|
| Hospital Charge Code |
Px09169084701
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$665.44 |
| 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 |
$887.25
|
| Rate for Payer: Cash Price |
$887.25
|
| 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 |
$665.44
|
| Rate for Payer: Provider Network of America Commercial |
$709.80
|
|
|
Family Psychotherapy W/Patient Present 50 Mins
|
Facility
|
OP
|
$887.25
|
|
|
Service Code
|
CPT 90847
|
| Hospital Charge Code |
Px09169084701
|
|
Hospital Revenue Code
|
916
|
| Min. Negotiated Rate |
$168.64 |
| Max. Negotiated Rate |
$887.25 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$625.51
|
| Rate for Payer: Aetna Workers' Compensation |
$625.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$614.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$614.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$699.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$699.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$699.15
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$683.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$699.15
|
| Rate for Payer: Cash Price |
$887.25
|
| Rate for Payer: Cash Price |
$887.25
|
| Rate for Payer: Cigna Commercial |
$543.00
|
| Rate for Payer: Cigna Medicare Advantage |
$505.73
|
| Rate for Payer: Family Health Partners Medicaid |
$224.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$558.97
|
| Rate for Payer: Healthy Blue Medicaid |
$241.92
|
| Rate for Payer: Home State Health Plan Exchange |
$505.73
|
| Rate for Payer: Home State Health Plan Medicaid |
$224.00
|
| Rate for Payer: Humana Medicare |
$665.44
|
| Rate for Payer: Mercy CarePlus Medicaid |
$224.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$665.44
|
| Rate for Payer: Provider Network of America Commercial |
$709.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$585.59
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$887.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$168.64
|
|
|
famotidine 20 mg/2 mL solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J1308
|
|
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
|
|
|
famotidine 20 mg/2 mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 63323073912
|
|
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
|
|
