|
Furosemide Injection
|
Facility
|
OP
|
$71.93
|
|
|
Service Code
|
CPT J1940
|
| Hospital Charge Code |
Px0636J194001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.00 |
| Max. Negotiated Rate |
$71.93 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$50.71
|
| Rate for Payer: Aetna Workers' Compensation |
$50.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$49.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$49.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$56.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$56.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$56.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$55.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$56.68
|
| Rate for Payer: Cash Price |
$71.93
|
| Rate for Payer: Cigna Commercial |
$44.02
|
| Rate for Payer: Cigna Medicare Advantage |
$41.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$45.32
|
| Rate for Payer: Home State Health Plan Exchange |
$41.00
|
| Rate for Payer: Humana Medicare |
$53.95
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$53.95
|
| Rate for Payer: Provider Network of America Commercial |
$57.54
|
| Rate for Payer: UnitedHealthcare Commercial |
$47.47
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$71.93
|
|
|
Furosemide Injection
|
Facility
|
IP
|
$71.93
|
|
|
Service Code
|
CPT J1940
|
| Hospital Charge Code |
Px0636J194001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$875.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$900.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$71.93
|
| Rate for Payer: Cash Price |
$71.93
|
| 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 |
$53.95
|
| Rate for Payer: Provider Network of America Commercial |
$57.54
|
|
|
gabapentin 100 mg capsule 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904666561
|
|
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
|
|
|
gabapentin 100 mg capsule 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904666561
|
|
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
|
|
|
gabapentin 100 mg capsule 100 Each Bottle
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 67877022201
|
|
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
|
|
|
gabapentin 100 mg capsule 100 Each Bottle
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 67877022201
|
|
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
|
|
|
gabapentin 300 mg capsule 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904666661
|
|
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
|
|
|
gabapentin 300 mg capsule 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904666661
|
|
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
|
|
|
Gad65 Ab, Serum
|
Facility
|
OP
|
$220.50
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
Px03028634104
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$22.36 |
| Max. Negotiated Rate |
$176.40 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$155.45
|
| Rate for Payer: Aetna Workers' Compensation |
$155.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$152.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$152.81
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$173.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$173.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$173.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$169.78
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$173.75
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$115.54
|
| Rate for Payer: Cigna Medicare Advantage |
$125.69
|
| Rate for Payer: Family Health Partners Medicaid |
$29.69
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$138.91
|
| Rate for Payer: Healthy Blue Medicaid |
$32.07
|
| Rate for Payer: Home State Health Plan Exchange |
$125.69
|
| Rate for Payer: Home State Health Plan Medicaid |
$29.69
|
| Rate for Payer: Humana Medicare |
$165.38
|
| Rate for Payer: Mercy CarePlus Medicaid |
$29.69
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$165.38
|
| Rate for Payer: Provider Network of America Commercial |
$176.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$145.53
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$23.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.36
|
|
|
Gad65 Ab, Serum
|
Facility
|
IP
|
$220.50
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
Px03028634104
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$165.38 |
| 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 |
$220.50
|
| Rate for Payer: Cash Price |
$220.50
|
| 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 |
$165.38
|
| Rate for Payer: Provider Network of America Commercial |
$176.40
|
|
|
gadobutrol 1 mmol/mL solution 10 mL Syringe
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
NDC 50419032528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$202.92 |
| Max. Negotiated Rate |
$356.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$250.98
|
| Rate for Payer: Aetna Workers' Compensation |
$250.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$246.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$246.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$280.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$280.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$280.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$274.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$280.53
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cigna Commercial |
$217.87
|
| Rate for Payer: Cigna Medicare Advantage |
$202.92
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$224.28
|
| Rate for Payer: Home State Health Plan Exchange |
$202.92
|
| Rate for Payer: Humana Medicare |
$267.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$267.00
|
| Rate for Payer: Provider Network of America Commercial |
$284.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$234.96
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$356.00
|
|
|
gadobutrol 1 mmol/mL solution 10 mL Syringe
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
NDC 50419032528
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$267.00 |
| 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 |
$356.00
|
| Rate for Payer: Cash Price |
$356.00
|
| 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 |
$267.00
|
| Rate for Payer: Provider Network of America Commercial |
$284.80
|
|
|
gadobutrol 1 mmol/mL solution 10 mL Syringe
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
HCPCS A9585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$267.00 |
| 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 |
$356.00
|
| Rate for Payer: Cash Price |
$356.00
|
| 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 |
$267.00
|
| Rate for Payer: Provider Network of America Commercial |
$284.80
|
|
|
gadobutrol 1 mmol/mL solution 10 mL Syringe
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
NDC 50419032523
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$267.00 |
| 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 |
$356.00
|
| Rate for Payer: Cash Price |
$356.00
|
| 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 |
$267.00
|
| Rate for Payer: Provider Network of America Commercial |
$284.80
|
|
|
gadobutrol 1 mmol/mL solution 10 mL Syringe
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
HCPCS A9585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$202.92 |
| Max. Negotiated Rate |
$356.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$250.98
|
| Rate for Payer: Aetna Workers' Compensation |
$250.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$246.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$246.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$280.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$280.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$280.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$274.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$280.53
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cigna Commercial |
$217.87
|
| Rate for Payer: Cigna Medicare Advantage |
$202.92
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$224.28
|
| Rate for Payer: Home State Health Plan Exchange |
$202.92
|
| Rate for Payer: Humana Medicare |
$267.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$267.00
|
| Rate for Payer: Provider Network of America Commercial |
$284.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$234.96
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$356.00
|
|
|
gadobutrol 1 mmol/mL solution 10 mL Syringe
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
NDC 50419032523
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$202.92 |
| Max. Negotiated Rate |
$356.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$250.98
|
| Rate for Payer: Aetna Workers' Compensation |
$250.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$246.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$246.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$280.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$280.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$280.53
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$274.12
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$280.53
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cigna Commercial |
$217.87
|
| Rate for Payer: Cigna Medicare Advantage |
$202.92
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$224.28
|
| Rate for Payer: Home State Health Plan Exchange |
$202.92
|
| Rate for Payer: Humana Medicare |
$267.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$267.00
|
| Rate for Payer: Provider Network of America Commercial |
$284.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$234.96
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$356.00
|
|
|
gadoxetate 0.25 mmol/mL (181.43 mg/mL) solution 10 mL Vial
|
Facility
|
OP
|
$567.84
|
|
|
Service Code
|
NDC 50419032001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$323.67 |
| Max. Negotiated Rate |
$567.84 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$400.33
|
| Rate for Payer: Aetna Workers' Compensation |
$400.33
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$393.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$393.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$447.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$447.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$447.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$437.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$447.46
|
| Rate for Payer: Cash Price |
$567.84
|
| Rate for Payer: Cigna Commercial |
$347.52
|
| Rate for Payer: Cigna Medicare Advantage |
$323.67
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$357.74
|
| Rate for Payer: Home State Health Plan Exchange |
$323.67
|
| Rate for Payer: Humana Medicare |
$425.88
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$425.88
|
| Rate for Payer: Provider Network of America Commercial |
$454.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$374.77
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$567.84
|
|
|
gadoxetate 0.25 mmol/mL (181.43 mg/mL) solution 10 mL Vial
|
Facility
|
IP
|
$567.84
|
|
|
Service Code
|
HCPCS A9581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$425.88 |
| 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 |
$567.84
|
| Rate for Payer: Cash Price |
$567.84
|
| 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 |
$425.88
|
| Rate for Payer: Provider Network of America Commercial |
$454.27
|
|
|
gadoxetate 0.25 mmol/mL (181.43 mg/mL) solution 10 mL Vial
|
Facility
|
IP
|
$567.84
|
|
|
Service Code
|
NDC 50419032001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$425.88 |
| 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 |
$567.84
|
| Rate for Payer: Cash Price |
$567.84
|
| 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 |
$425.88
|
| Rate for Payer: Provider Network of America Commercial |
$454.27
|
|
|
gadoxetate 0.25 mmol/mL (181.43 mg/mL) solution 10 mL Vial
|
Facility
|
OP
|
$567.84
|
|
|
Service Code
|
HCPCS A9581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$323.67 |
| Max. Negotiated Rate |
$567.84 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$400.33
|
| Rate for Payer: Aetna Workers' Compensation |
$400.33
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$393.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$393.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$447.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$447.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$447.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$437.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$447.46
|
| Rate for Payer: Cash Price |
$567.84
|
| Rate for Payer: Cigna Commercial |
$347.52
|
| Rate for Payer: Cigna Medicare Advantage |
$323.67
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$357.74
|
| Rate for Payer: Home State Health Plan Exchange |
$323.67
|
| Rate for Payer: Humana Medicare |
$425.88
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$425.88
|
| Rate for Payer: Provider Network of America Commercial |
$454.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$374.77
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$567.84
|
|
|
Garamycin gentamicin inj
|
Facility
|
IP
|
$26.25
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
Px0636J158001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.69 |
| 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 |
$26.25
|
| Rate for Payer: Cash Price |
$26.25
|
| 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 |
$19.69
|
| Rate for Payer: Provider Network of America Commercial |
$21.00
|
|
|
Garamycin gentamicin inj
|
Facility
|
OP
|
$26.25
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
Px0636J158001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$18.51
|
| Rate for Payer: Aetna Workers' Compensation |
$18.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$18.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$18.19
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$20.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$20.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$20.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$20.21
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$20.68
|
| Rate for Payer: Cash Price |
$26.25
|
| Rate for Payer: Cigna Commercial |
$16.07
|
| Rate for Payer: Cigna Medicare Advantage |
$14.96
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$16.54
|
| Rate for Payer: Home State Health Plan Exchange |
$14.96
|
| Rate for Payer: Humana Medicare |
$19.69
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$19.69
|
| Rate for Payer: Provider Network of America Commercial |
$21.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$17.32
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$26.25
|
|
|
Gas Dilut/Washout Lung Vol W/WO Distrib Vent&V
|
Professional
|
Both
|
$676.00
|
|
|
Service Code
|
CPT 94727
|
| Hospital Charge Code |
Px00000094727
|
|
Hospital Revenue Code
|
520
|
| Min. Negotiated Rate |
$55.16 |
| Max. Negotiated Rate |
$55.16 |
| Rate for Payer: Cash Price |
$676.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$55.16
|
|
|
Gases Blood Ph Direct Meas Xcpt Pulse Oximitry
|
Facility
|
IP
|
$347.55
|
|
|
Service Code
|
CPT 82805
|
| Hospital Charge Code |
Px03018280501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$260.66 |
| 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 |
$347.55
|
| Rate for Payer: Cash Price |
$347.55
|
| 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 |
$260.66
|
| Rate for Payer: Provider Network of America Commercial |
$278.04
|
|
|
Gases Blood Ph Direct Meas Xcpt Pulse Oximitry
|
Facility
|
OP
|
$347.55
|
|
|
Service Code
|
CPT 82805
|
| Hospital Charge Code |
Px03018280501
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$74.72 |
| Max. Negotiated Rate |
$278.04 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$245.02
|
| Rate for Payer: Aetna Workers' Compensation |
$245.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$240.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$240.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$273.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$273.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$273.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$267.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$273.87
|
| Rate for Payer: Cash Price |
$347.55
|
| Rate for Payer: Cash Price |
$347.55
|
| Rate for Payer: Cigna Commercial |
$182.12
|
| Rate for Payer: Cigna Medicare Advantage |
$198.10
|
| Rate for Payer: Family Health Partners Medicaid |
$99.25
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$218.96
|
| Rate for Payer: Healthy Blue Medicaid |
$107.19
|
| Rate for Payer: Home State Health Plan Exchange |
$198.10
|
| Rate for Payer: Home State Health Plan Medicaid |
$99.25
|
| Rate for Payer: Humana Medicare |
$260.66
|
| Rate for Payer: Mercy CarePlus Medicaid |
$99.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$260.66
|
| Rate for Payer: Provider Network of America Commercial |
$278.04
|
| Rate for Payer: UnitedHealthcare Commercial |
$229.38
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$78.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$74.72
|
|
