|
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
|
|
|
famotidine 20 mg/2 mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J1308
|
|
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
|
|
|
famotidine 20 mg tablet 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904719361
|
|
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
|
|
|
famotidine 20 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904719361
|
|
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
|
|
|
fat emulsion 20 % emulsion 250 mL Flex Cont
|
Facility
|
OP
|
$193.68
|
|
|
Service Code
|
NDC 65219053301
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$110.40 |
| Max. Negotiated Rate |
$193.68 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$136.54
|
| Rate for Payer: Aetna Workers' Compensation |
$136.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$134.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$134.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$152.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$152.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$152.62
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$149.13
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$152.62
|
| Rate for Payer: Cash Price |
$193.68
|
| Rate for Payer: Cigna Commercial |
$118.53
|
| Rate for Payer: Cigna Medicare Advantage |
$110.40
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$122.02
|
| Rate for Payer: Home State Health Plan Exchange |
$110.40
|
| Rate for Payer: Humana Medicare |
$145.26
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$145.26
|
| Rate for Payer: Provider Network of America Commercial |
$154.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$127.83
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$193.68
|
|
|
fat emulsion 20 % emulsion 250 mL Flex Cont
|
Facility
|
IP
|
$193.68
|
|
|
Service Code
|
NDC 65219053301
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$145.26 |
| 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 |
$193.68
|
| Rate for Payer: Cash Price |
$193.68
|
| 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 |
$145.26
|
| Rate for Payer: Provider Network of America Commercial |
$154.94
|
|
|
Fat Stain Feces Urine/Respir Secretions
|
Facility
|
IP
|
$115.50
|
|
|
Service Code
|
CPT 89125
|
| Hospital Charge Code |
Px03008912501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$86.62 |
| 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 |
$115.50
|
| Rate for Payer: Cash Price |
$115.50
|
| 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 |
$86.62
|
| Rate for Payer: Provider Network of America Commercial |
$92.40
|
|
|
Fat Stain Feces Urine/Respir Secretions
|
Facility
|
OP
|
$115.50
|
|
|
Service Code
|
CPT 89125
|
| Hospital Charge Code |
Px03008912501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$92.40 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$81.43
|
| Rate for Payer: Aetna Workers' Compensation |
$81.43
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$80.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$80.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$91.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$91.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$91.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$88.94
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$91.01
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cigna Commercial |
$60.52
|
| Rate for Payer: Cigna Medicare Advantage |
$65.83
|
| Rate for Payer: Family Health Partners Medicaid |
$7.41
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$72.77
|
| Rate for Payer: Healthy Blue Medicaid |
$8.00
|
| Rate for Payer: Home State Health Plan Exchange |
$65.83
|
| Rate for Payer: Home State Health Plan Medicaid |
$7.41
|
| Rate for Payer: Humana Medicare |
$86.62
|
| Rate for Payer: Mercy CarePlus Medicaid |
$7.41
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$86.62
|
| Rate for Payer: Provider Network of America Commercial |
$92.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$76.23
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$5.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.58
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$7,362.87
|
|
|
Service Code
|
APR-DRG 5312
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$7,362.87 |
| 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 |
$7,362.87
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$7,362.87
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$7,362.87
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$7,362.87
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$20,184.10
|
|
|
Service Code
|
APR-DRG 5314
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$20,184.10 |
| 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 |
$20,184.10
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$20,184.10
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$20,184.10
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$20,184.10
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
APR-DRG 5311
|
| 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: Family Health Partners Medicaid |
$5,276.23
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$5,276.23
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$5,276.23
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$5,276.23
|
|
|
FEMALE REPRODUCTIVE SYSTEM INFECTIONS
|
Facility
|
IP
|
$12,602.12
|
|
|
Service Code
|
APR-DRG 5313
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$12,602.12 |
| 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 |
$12,602.12
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$12,602.12
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$12,602.12
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$12,602.12
|
|
|
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
|
Facility
|
IP
|
$7,126.19
|
|
|
Service Code
|
APR-DRG 5301
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$7,126.19 |
| 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 |
$7,126.19
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$7,126.19
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$7,126.19
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$7,126.19
|
|
|
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
|
Facility
|
IP
|
$14,420.65
|
|
|
Service Code
|
APR-DRG 5303
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$14,420.65 |
| 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 |
$14,420.65
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$14,420.65
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$14,420.65
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$14,420.65
|
|
|
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
|
Facility
|
IP
|
$9,259.98
|
|
|
Service Code
|
APR-DRG 5302
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$9,259.98 |
| 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 |
$9,259.98
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$9,259.98
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$9,259.98
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$9,259.98
|
|
|
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
|
Facility
|
IP
|
$23,652.89
|
|
|
Service Code
|
APR-DRG 5304
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$23,652.89 |
| 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 |
$23,652.89
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$23,652.89
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$23,652.89
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$23,652.89
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$49,436.80
|
|
|
Service Code
|
APR-DRG 5144
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$49,436.80 |
| 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 |
$49,436.80
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$49,436.80
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$49,436.80
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$49,436.80
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$6,520.31
|
|
|
Service Code
|
MSDRG 748
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,520.31 |
| 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 |
$6,520.31
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$11,679.45
|
|
|
Service Code
|
APR-DRG 5141
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$11,679.45 |
| 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 |
$11,679.45
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$11,679.45
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$11,679.45
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$11,679.45
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$17,630.58
|
|
|
Service Code
|
APR-DRG 5142
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$17,630.58 |
| 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 |
$17,630.58
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$17,630.58
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$17,630.58
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$17,630.58
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$23,847.97
|
|
|
Service Code
|
APR-DRG 5143
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$23,847.97 |
| 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 |
$23,847.97
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$23,847.97
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$23,847.97
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$23,847.97
|
|
|
fenofibrate 160 mg tablet 1 Each BLIST PACK
|
Facility
|
OP
|
$12.79
|
|
|
Service Code
|
NDC 50268031311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.29 |
| Max. Negotiated Rate |
$12.79 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$9.02
|
| Rate for Payer: Aetna Workers' Compensation |
$9.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$8.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$8.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$10.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$10.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$10.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$9.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$10.08
|
| Rate for Payer: Cash Price |
$12.79
|
| Rate for Payer: Cigna Commercial |
$7.83
|
| Rate for Payer: Cigna Medicare Advantage |
$7.29
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$8.06
|
| Rate for Payer: Home State Health Plan Exchange |
$7.29
|
| Rate for Payer: Humana Medicare |
$9.59
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$9.59
|
| Rate for Payer: Provider Network of America Commercial |
$10.23
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.44
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$12.79
|
|
|
fenofibrate 160 mg tablet 1 Each BLIST PACK
|
Facility
|
IP
|
$12.79
|
|
|
Service Code
|
NDC 50268031311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.59 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$12.79
|
| Rate for Payer: Cash Price |
$12.79
|
| 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 |
$9.59
|
| Rate for Payer: Provider Network of America Commercial |
$10.23
|
|
|
fenofibrate 160 mg tablet 90 Each Bottle
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 70756021590
|
|
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
|
|
|
fenofibrate 160 mg tablet 90 Each Bottle
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 70756021590
|
|
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
|
|
