|
filgrastim 480 mcg/0.8 mL syringe 0.8 mL Syringe
|
Facility
|
OP
|
$2,125.72
|
|
|
Service Code
|
HCPCS J1442
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,211.66 |
| Max. Negotiated Rate |
$2,125.72 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$1,498.63
|
| Rate for Payer: Aetna Workers' Compensation |
$1,498.63
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$1,473.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$1,473.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$1,675.07
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$1,675.07
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$1,675.07
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$1,636.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$1,675.07
|
| Rate for Payer: Cash Price |
$2,125.72
|
| Rate for Payer: Cigna Commercial |
$1,300.94
|
| Rate for Payer: Cigna Medicare Advantage |
$1,211.66
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,339.20
|
| Rate for Payer: Home State Health Plan Exchange |
$1,211.66
|
| Rate for Payer: Humana Medicare |
$1,594.29
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,594.29
|
| Rate for Payer: Provider Network of America Commercial |
$1,700.58
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,402.98
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$2,125.72
|
|
|
filgrastim 480 mcg/0.8 mL syringe 0.8 mL Syringe
|
Facility
|
IP
|
$2,125.72
|
|
|
Service Code
|
NDC 55513020991
|
|
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 |
$2,125.72
|
| Rate for Payer: Cash Price |
$2,125.72
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,594.29
|
| Rate for Payer: Provider Network of America Commercial |
$1,700.58
|
|
|
filgrastim 480 mcg/0.8 mL syringe 0.8 mL Syringe
|
Facility
|
IP
|
$2,125.72
|
|
|
Service Code
|
HCPCS J1442
|
|
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 |
$2,125.72
|
| Rate for Payer: Cash Price |
$2,125.72
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$1,594.29
|
| Rate for Payer: Provider Network of America Commercial |
$1,700.58
|
|
|
filgrastim-ayow 300 mcg/0.5 mL syringe 0.5 mL Syringe
|
Facility
|
IP
|
$636.00
|
|
|
Service Code
|
HCPCS Q5125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$477.00 |
| 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 |
$636.00
|
| Rate for Payer: Cash Price |
$636.00
|
| 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 |
$477.00
|
| Rate for Payer: Provider Network of America Commercial |
$508.80
|
|
|
filgrastim-ayow 300 mcg/0.5 mL syringe 0.5 mL Syringe
|
Facility
|
IP
|
$636.00
|
|
|
Service Code
|
NDC 70121156801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$477.00 |
| 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 |
$636.00
|
| Rate for Payer: Cash Price |
$636.00
|
| 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 |
$477.00
|
| Rate for Payer: Provider Network of America Commercial |
$508.80
|
|
|
filgrastim-ayow 300 mcg/0.5 mL syringe 0.5 mL Syringe
|
Facility
|
OP
|
$636.00
|
|
|
Service Code
|
NDC 70121156801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$362.52 |
| Max. Negotiated Rate |
$636.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$448.38
|
| Rate for Payer: Aetna Workers' Compensation |
$448.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$440.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$440.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$501.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$501.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$501.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$489.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$501.17
|
| Rate for Payer: Cash Price |
$636.00
|
| Rate for Payer: Cigna Commercial |
$389.23
|
| Rate for Payer: Cigna Medicare Advantage |
$362.52
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$400.68
|
| Rate for Payer: Home State Health Plan Exchange |
$362.52
|
| Rate for Payer: Humana Medicare |
$477.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$477.00
|
| Rate for Payer: Provider Network of America Commercial |
$508.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$419.76
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$636.00
|
|
|
filgrastim-ayow 300 mcg/0.5 mL syringe 0.5 mL Syringe
|
Facility
|
OP
|
$636.00
|
|
|
Service Code
|
HCPCS Q5125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$362.52 |
| Max. Negotiated Rate |
$636.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$448.38
|
| Rate for Payer: Aetna Workers' Compensation |
$448.38
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$440.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$440.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$501.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$501.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$501.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$489.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$501.17
|
| Rate for Payer: Cash Price |
$636.00
|
| Rate for Payer: Cigna Commercial |
$389.23
|
| Rate for Payer: Cigna Medicare Advantage |
$362.52
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$400.68
|
| Rate for Payer: Home State Health Plan Exchange |
$362.52
|
| Rate for Payer: Humana Medicare |
$477.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$477.00
|
| Rate for Payer: Provider Network of America Commercial |
$508.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$419.76
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$636.00
|
|
|
filgrastim-ayow 480 mcg/0.8 mL syringe 0.8 mL Syringe
|
Facility
|
OP
|
$1,017.60
|
|
|
Service Code
|
HCPCS Q5125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$580.03 |
| Max. Negotiated Rate |
$1,017.60 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$717.41
|
| Rate for Payer: Aetna Workers' Compensation |
$717.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$705.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$705.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$801.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$801.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$801.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$783.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$801.87
|
| Rate for Payer: Cash Price |
$1,017.60
|
| Rate for Payer: Cigna Commercial |
$622.77
|
| Rate for Payer: Cigna Medicare Advantage |
$580.03
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$641.09
|
| Rate for Payer: Home State Health Plan Exchange |
$580.03
|
| Rate for Payer: Humana Medicare |
$763.20
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$763.20
|
| Rate for Payer: Provider Network of America Commercial |
$814.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$671.62
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,017.60
|
|
|
filgrastim-ayow 480 mcg/0.8 mL syringe 0.8 mL Syringe
|
Facility
|
OP
|
$1,017.60
|
|
|
Service Code
|
NDC 70121157001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$580.03 |
| Max. Negotiated Rate |
$1,017.60 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$717.41
|
| Rate for Payer: Aetna Workers' Compensation |
$717.41
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$705.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$705.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$801.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$801.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$801.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$783.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$801.87
|
| Rate for Payer: Cash Price |
$1,017.60
|
| Rate for Payer: Cigna Commercial |
$622.77
|
| Rate for Payer: Cigna Medicare Advantage |
$580.03
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$641.09
|
| Rate for Payer: Home State Health Plan Exchange |
$580.03
|
| Rate for Payer: Humana Medicare |
$763.20
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$763.20
|
| Rate for Payer: Provider Network of America Commercial |
$814.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$671.62
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,017.60
|
|
|
filgrastim-ayow 480 mcg/0.8 mL syringe 0.8 mL Syringe
|
Facility
|
IP
|
$1,017.60
|
|
|
Service Code
|
NDC 70121157001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$763.20 |
| 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 |
$1,017.60
|
| Rate for Payer: Cash Price |
$1,017.60
|
| 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 |
$763.20
|
| Rate for Payer: Provider Network of America Commercial |
$814.08
|
|
|
filgrastim-ayow 480 mcg/0.8 mL syringe 0.8 mL Syringe
|
Facility
|
IP
|
$1,017.60
|
|
|
Service Code
|
HCPCS Q5125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$763.20 |
| 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 |
$1,017.60
|
| Rate for Payer: Cash Price |
$1,017.60
|
| 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 |
$763.20
|
| Rate for Payer: Provider Network of America Commercial |
$814.08
|
|
|
filgrastim-sndz 480 mcg/0.8 mL syringe 0.8 mL Syringe
|
Facility
|
IP
|
$1,097.45
|
|
|
Service Code
|
HCPCS Q5101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$823.09 |
| 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 |
$1,097.45
|
| Rate for Payer: Cash Price |
$1,097.45
|
| 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 |
$823.09
|
| Rate for Payer: Provider Network of America Commercial |
$877.96
|
|
|
filgrastim-sndz 480 mcg/0.8 mL syringe 0.8 mL Syringe
|
Facility
|
OP
|
$1,097.45
|
|
|
Service Code
|
HCPCS Q5101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$625.55 |
| Max. Negotiated Rate |
$1,097.45 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$773.70
|
| Rate for Payer: Aetna Workers' Compensation |
$773.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$760.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$760.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$864.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$864.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$864.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$845.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$864.79
|
| Rate for Payer: Cash Price |
$1,097.45
|
| Rate for Payer: Cigna Commercial |
$671.64
|
| Rate for Payer: Cigna Medicare Advantage |
$625.55
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$691.39
|
| Rate for Payer: Home State Health Plan Exchange |
$625.55
|
| Rate for Payer: Humana Medicare |
$823.09
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$823.09
|
| Rate for Payer: Provider Network of America Commercial |
$877.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$724.32
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,097.45
|
|
|
filgrastim-sndz 480 mcg/0.8 mL syringe 0.8 mL Syringe
|
Facility
|
OP
|
$1,097.45
|
|
|
Service Code
|
NDC 61314032601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$625.55 |
| Max. Negotiated Rate |
$1,097.45 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$773.70
|
| Rate for Payer: Aetna Workers' Compensation |
$773.70
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$760.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$760.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$864.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$864.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$864.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$845.04
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$864.79
|
| Rate for Payer: Cash Price |
$1,097.45
|
| Rate for Payer: Cigna Commercial |
$671.64
|
| Rate for Payer: Cigna Medicare Advantage |
$625.55
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$691.39
|
| Rate for Payer: Home State Health Plan Exchange |
$625.55
|
| Rate for Payer: Humana Medicare |
$823.09
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$823.09
|
| Rate for Payer: Provider Network of America Commercial |
$877.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$724.32
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,097.45
|
|
|
filgrastim-sndz 480 mcg/0.8 mL syringe 0.8 mL Syringe
|
Facility
|
IP
|
$1,097.45
|
|
|
Service Code
|
NDC 61314032601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$823.09 |
| 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 |
$1,097.45
|
| Rate for Payer: Cash Price |
$1,097.45
|
| 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 |
$823.09
|
| Rate for Payer: Provider Network of America Commercial |
$877.96
|
|
|
finasteride 5 mg tablet 50 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904683006
|
|
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
|
|
|
finasteride 5 mg tablet 50 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904683006
|
|
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
|
|
|
Fine Needle Aspiration Bx W/US Gdn Ea Addl
|
Facility
|
OP
|
$30.03
|
|
|
Service Code
|
CPT 10006
|
| Hospital Charge Code |
Px09831000601
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$17.12 |
| Max. Negotiated Rate |
$30.03 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$21.17
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$20.16
|
| Rate for Payer: Aetna Workers' Compensation |
$20.16
|
| Rate for Payer: Aetna Workers' Compensation |
$21.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$19.82
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$20.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$19.82
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$20.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$23.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$22.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$22.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$23.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$23.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$22.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$23.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$22.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$22.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$23.66
|
| Rate for Payer: Cash Price |
$30.03
|
| Rate for Payer: Cash Price |
$28.60
|
| Rate for Payer: Cigna Commercial |
$17.50
|
| Rate for Payer: Cigna Commercial |
$18.38
|
| Rate for Payer: Cigna Medicare Advantage |
$17.12
|
| Rate for Payer: Cigna Medicare Advantage |
$16.30
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$18.92
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$18.02
|
| Rate for Payer: Home State Health Plan Exchange |
$16.30
|
| Rate for Payer: Home State Health Plan Exchange |
$17.12
|
| Rate for Payer: Humana Medicare |
$22.52
|
| Rate for Payer: Humana Medicare |
$21.45
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$21.45
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$22.52
|
| Rate for Payer: Provider Network of America Commercial |
$24.02
|
| Rate for Payer: Provider Network of America Commercial |
$22.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.82
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$28.60
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$30.03
|
|
|
Fine Needle Aspiration Bx W/US Gdn Ea Addl
|
Facility
|
IP
|
$30.03
|
|
|
Service Code
|
CPT 10006
|
| Hospital Charge Code |
Px09831000601
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$22.52 |
| 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 |
$30.03
|
| Rate for Payer: Cash Price |
$28.60
|
| Rate for Payer: Cash Price |
$30.03
|
| Rate for Payer: Cash Price |
$28.60
|
| 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 |
$22.52
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$21.45
|
| Rate for Payer: Provider Network of America Commercial |
$24.02
|
| Rate for Payer: Provider Network of America Commercial |
$22.88
|
|
|
Fluconazole
|
Facility
|
OP
|
$165.28
|
|
|
Service Code
|
HCPCS J1450
|
| Hospital Charge Code |
Px0636J145001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.21 |
| Max. Negotiated Rate |
$165.28 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$116.52
|
| Rate for Payer: Aetna Workers' Compensation |
$116.52
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$114.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$114.54
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$130.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$130.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$130.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$127.27
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$130.24
|
| Rate for Payer: Cash Price |
$165.28
|
| Rate for Payer: Cigna Commercial |
$101.15
|
| Rate for Payer: Cigna Medicare Advantage |
$94.21
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$104.13
|
| Rate for Payer: Home State Health Plan Exchange |
$94.21
|
| Rate for Payer: Humana Medicare |
$123.96
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$123.96
|
| Rate for Payer: Provider Network of America Commercial |
$132.22
|
| Rate for Payer: UnitedHealthcare Commercial |
$109.08
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$165.28
|
|
|
Fluconazole
|
Facility
|
IP
|
$165.28
|
|
|
Service Code
|
HCPCS J1450
|
| Hospital Charge Code |
Px0636J145001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$123.96 |
| 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 |
$165.28
|
| Rate for Payer: Cash Price |
$165.28
|
| 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 |
$123.96
|
| Rate for Payer: Provider Network of America Commercial |
$132.22
|
|
|
fluconazole 100 mg tablet 50 Each BLIST PACK
|
Facility
|
IP
|
$5.30
|
|
|
Service Code
|
NDC 00904650006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.98 |
| 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 |
$5.30
|
| Rate for Payer: Cash Price |
$5.30
|
| 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 |
$3.98
|
| Rate for Payer: Provider Network of America Commercial |
$4.24
|
|
|
fluconazole 100 mg tablet 50 Each BLIST PACK
|
Facility
|
OP
|
$5.30
|
|
|
Service Code
|
NDC 00904650006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$5.30 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$3.74
|
| Rate for Payer: Aetna Workers' Compensation |
$3.74
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$3.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$3.67
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$4.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$4.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$4.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$4.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$4.18
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Cigna Commercial |
$3.24
|
| Rate for Payer: Cigna Medicare Advantage |
$3.02
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$3.34
|
| Rate for Payer: Home State Health Plan Exchange |
$3.02
|
| Rate for Payer: Humana Medicare |
$3.98
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3.98
|
| Rate for Payer: Provider Network of America Commercial |
$4.24
|
| Rate for Payer: UnitedHealthcare Commercial |
$3.50
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$5.30
|
|
|
fluconazole 150 mg tablet 12 Each BLIST PACK
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 57237000511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$3.17
|
| Rate for Payer: Aetna Workers' Compensation |
$3.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$3.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$3.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$3.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$3.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$3.55
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$3.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$3.55
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$2.75
|
| Rate for Payer: Cigna Medicare Advantage |
$2.56
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$2.83
|
| Rate for Payer: Home State Health Plan Exchange |
$2.56
|
| Rate for Payer: Humana Medicare |
$3.38
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$3.38
|
| Rate for Payer: Provider Network of America Commercial |
$3.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.97
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$4.50
|
|
|
fluconazole 150 mg tablet 12 Each BLIST PACK
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 57237000511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.38 |
| 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 |
$4.50
|
| Rate for Payer: Cash Price |
$4.50
|
| 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 |
$3.38
|
| Rate for Payer: Provider Network of America Commercial |
$3.60
|
|
