|
allopurinol 100 mg tablet 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687067711
|
|
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
|
|
|
allopurinol 100 mg tablet 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687067711
|
|
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
|
|
|
ALPRAZolam 0.5 mg tablet 100 Each Bottle
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 65862067701
|
|
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
|
|
|
ALPRAZolam 0.5 mg tablet 100 Each Bottle
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 65862067701
|
|
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
|
|
|
ALPRAZolam 0.5 mg tablet 100 Each Bottle
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00228202910
|
|
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
|
|
|
ALPRAZolam 0.5 mg tablet 100 Each Bottle
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00228202910
|
|
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
|
|
|
alteplase 2 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$777.72
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$583.29 |
| 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 |
$777.72
|
| Rate for Payer: Cash Price |
$777.72
|
| 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 |
$583.29
|
| Rate for Payer: Provider Network of America Commercial |
$622.18
|
|
|
alteplase 2 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$777.72
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$443.30 |
| Max. Negotiated Rate |
$777.72 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$548.29
|
| Rate for Payer: Aetna Workers' Compensation |
$548.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$538.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$538.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$612.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$612.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$612.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$598.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$612.84
|
| Rate for Payer: Cash Price |
$777.72
|
| Rate for Payer: Cigna Commercial |
$475.96
|
| Rate for Payer: Cigna Medicare Advantage |
$443.30
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$489.96
|
| Rate for Payer: Home State Health Plan Exchange |
$443.30
|
| Rate for Payer: Humana Medicare |
$583.29
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$583.29
|
| Rate for Payer: Provider Network of America Commercial |
$622.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$513.30
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$777.72
|
|
|
alteplase 2 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$777.72
|
|
|
Service Code
|
NDC 50242004164
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$583.29 |
| 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 |
$777.72
|
| Rate for Payer: Cash Price |
$777.72
|
| 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 |
$583.29
|
| Rate for Payer: Provider Network of America Commercial |
$622.18
|
|
|
alteplase 2 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$777.72
|
|
|
Service Code
|
NDC 50242004164
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$443.30 |
| Max. Negotiated Rate |
$777.72 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$548.29
|
| Rate for Payer: Aetna Workers' Compensation |
$548.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$538.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$538.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$612.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$612.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$612.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$598.84
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$612.84
|
| Rate for Payer: Cash Price |
$777.72
|
| Rate for Payer: Cigna Commercial |
$475.96
|
| Rate for Payer: Cigna Medicare Advantage |
$443.30
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$489.96
|
| Rate for Payer: Home State Health Plan Exchange |
$443.30
|
| Rate for Payer: Humana Medicare |
$583.29
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$583.29
|
| Rate for Payer: Provider Network of America Commercial |
$622.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$513.30
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$777.72
|
|
|
Alteplase recombinant
|
Facility
|
OP
|
$26,576.27
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
Px0636J299701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15,148.47 |
| Max. Negotiated Rate |
$26,576.27 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$18,736.27
|
| Rate for Payer: Aetna Workers' Compensation |
$18,736.27
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$18,417.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$18,417.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$20,942.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$20,942.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$20,942.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$20,463.73
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$20,942.10
|
| Rate for Payer: Cash Price |
$26,576.27
|
| Rate for Payer: Cigna Commercial |
$16,264.68
|
| Rate for Payer: Cigna Medicare Advantage |
$15,148.47
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$16,743.05
|
| Rate for Payer: Home State Health Plan Exchange |
$15,148.47
|
| Rate for Payer: Humana Medicare |
$19,932.20
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$19,932.20
|
| Rate for Payer: Provider Network of America Commercial |
$21,261.02
|
| Rate for Payer: UnitedHealthcare Commercial |
$17,540.34
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$26,576.27
|
|
|
Alteplase recombinant
|
Facility
|
IP
|
$26,576.27
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
Px0636J299701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$21,261.02 |
| 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 |
$26,576.27
|
| Rate for Payer: Cash Price |
$26,576.27
|
| 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 |
$19,932.20
|
| Rate for Payer: Provider Network of America Commercial |
$21,261.02
|
|
|
ALTERATION IN CONSCIOUSNESS
|
Facility
|
IP
|
$6,692.59
|
|
|
Service Code
|
APR-DRG 0521
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,692.59 |
| 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 |
$6,692.59
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$6,692.59
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$6,692.59
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$6,692.59
|
|
|
ALTERATION IN CONSCIOUSNESS
|
Facility
|
IP
|
$8,577.69
|
|
|
Service Code
|
APR-DRG 0522
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$8,577.69 |
| 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 |
$8,577.69
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$8,577.69
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$8,577.69
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$8,577.69
|
|
|
ALTERATION IN CONSCIOUSNESS
|
Facility
|
IP
|
$12,451.42
|
|
|
Service Code
|
APR-DRG 0523
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$12,451.42 |
| 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 |
$12,451.42
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$12,451.42
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$12,451.42
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$12,451.42
|
|
|
ALTERATION IN CONSCIOUSNESS
|
Facility
|
IP
|
$21,972.12
|
|
|
Service Code
|
APR-DRG 0524
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$21,972.12 |
| 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 |
$21,972.12
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$21,972.12
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$21,972.12
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$21,972.12
|
|
|
alum-mag hydroxide-simeth 200-200-20 mg/5 mL suspension 30 mL Cup
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00904732562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.75 |
| 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 |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| 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
|
|
|
alum-mag hydroxide-simeth 200-200-20 mg/5 mL suspension 30 mL Cup
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00904732562
|
|
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
|
|
|
amantadine 100 mg capsule 1 Each BLIST PACK
|
Facility
|
IP
|
$7.98
|
|
|
Service Code
|
NDC 50268006911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.99 |
| 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 |
$7.98
|
| Rate for Payer: Cash Price |
$7.98
|
| 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 |
$5.99
|
| Rate for Payer: Provider Network of America Commercial |
$6.38
|
|
|
amantadine 100 mg capsule 1 Each BLIST PACK
|
Facility
|
OP
|
$7.98
|
|
|
Service Code
|
NDC 50268006911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$7.98 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5.63
|
| Rate for Payer: Aetna Workers' Compensation |
$5.63
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$6.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$6.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$6.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$6.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$6.29
|
| Rate for Payer: Cash Price |
$7.98
|
| Rate for Payer: Cigna Commercial |
$4.88
|
| Rate for Payer: Cigna Medicare Advantage |
$4.55
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$5.03
|
| Rate for Payer: Home State Health Plan Exchange |
$4.55
|
| Rate for Payer: Humana Medicare |
$5.99
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5.99
|
| Rate for Payer: Provider Network of America Commercial |
$6.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.27
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7.98
|
|
|
amantadine 100 mg capsule 50 Each BLIST PACK
|
Facility
|
OP
|
$7.98
|
|
|
Service Code
|
NDC 50268006915
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$7.98 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5.63
|
| Rate for Payer: Aetna Workers' Compensation |
$5.63
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$6.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$6.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$6.29
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$6.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$6.29
|
| Rate for Payer: Cash Price |
$7.98
|
| Rate for Payer: Cigna Commercial |
$4.88
|
| Rate for Payer: Cigna Medicare Advantage |
$4.55
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$5.03
|
| Rate for Payer: Home State Health Plan Exchange |
$4.55
|
| Rate for Payer: Humana Medicare |
$5.99
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5.99
|
| Rate for Payer: Provider Network of America Commercial |
$6.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.27
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7.98
|
|
|
amantadine 100 mg capsule 50 Each BLIST PACK
|
Facility
|
OP
|
$5.61
|
|
|
Service Code
|
NDC 00904704206
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$5.61 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$3.96
|
| Rate for Payer: Aetna Workers' Compensation |
$3.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$3.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$3.89
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$4.42
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$4.42
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$4.42
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$4.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$4.42
|
| Rate for Payer: Cash Price |
$5.61
|
| Rate for Payer: Cigna Commercial |
$3.43
|
| Rate for Payer: Cigna Medicare Advantage |
$3.20
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$3.53
|
| Rate for Payer: Home State Health Plan Exchange |
$3.20
|
| Rate for Payer: Humana Medicare |
$4.21
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$4.21
|
| Rate for Payer: Provider Network of America Commercial |
$4.49
|
| Rate for Payer: UnitedHealthcare Commercial |
$3.70
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$5.61
|
|
|
amantadine 100 mg capsule 50 Each BLIST PACK
|
Facility
|
IP
|
$5.61
|
|
|
Service Code
|
NDC 00904704206
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.21 |
| 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 |
$5.61
|
| Rate for Payer: Cash Price |
$5.61
|
| 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 |
$4.21
|
| Rate for Payer: Provider Network of America Commercial |
$4.49
|
|
|
amantadine 100 mg capsule 50 Each BLIST PACK
|
Facility
|
IP
|
$7.98
|
|
|
Service Code
|
NDC 50268006915
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.99 |
| 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 |
$7.98
|
| Rate for Payer: Cash Price |
$7.98
|
| 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 |
$5.99
|
| Rate for Payer: Provider Network of America Commercial |
$6.38
|
|
|
amino acids-protein hydrolys 15 gram- 100 kcal/30 mL liquid in packet 30 mL Packet
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 26974041017
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
