|
gemcitabine 200 mg/5.26 mL (38 mg/mL) solution 5.26 mL Vial
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.05 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$45.83
|
| Rate for Payer: Aetna Workers' Compensation |
$45.83
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$45.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$45.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$51.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$51.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$51.22
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$50.05
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$51.22
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$39.78
|
| Rate for Payer: Cigna Medicare Advantage |
$37.05
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$40.95
|
| Rate for Payer: Home State Health Plan Exchange |
$37.05
|
| Rate for Payer: Humana Medicare |
$48.75
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$48.75
|
| Rate for Payer: Provider Network of America Commercial |
$52.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$42.90
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$65.00
|
|
|
gemcitabine 2 gram/52.6 mL (38 mg/mL) solution 52.6 mL Vial
|
Facility
|
IP
|
$113.40
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.05 |
| 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 |
$113.40
|
| Rate for Payer: Cash Price |
$113.40
|
| 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 |
$85.05
|
| Rate for Payer: Provider Network of America Commercial |
$90.72
|
|
|
gemcitabine 2 gram/52.6 mL (38 mg/mL) solution 52.6 mL Vial
|
Facility
|
OP
|
$113.40
|
|
|
Service Code
|
NDC 00409018225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.64 |
| Max. Negotiated Rate |
$113.40 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$79.95
|
| Rate for Payer: Aetna Workers' Compensation |
$79.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$78.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$78.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$89.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$89.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$89.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$87.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$89.36
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$69.40
|
| Rate for Payer: Cigna Medicare Advantage |
$64.64
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$71.44
|
| Rate for Payer: Home State Health Plan Exchange |
$64.64
|
| Rate for Payer: Humana Medicare |
$85.05
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$85.05
|
| Rate for Payer: Provider Network of America Commercial |
$90.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$74.84
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$113.40
|
|
|
gemcitabine 2 gram/52.6 mL (38 mg/mL) solution 52.6 mL Vial
|
Facility
|
OP
|
$113.40
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.64 |
| Max. Negotiated Rate |
$113.40 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$79.95
|
| Rate for Payer: Aetna Workers' Compensation |
$79.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$78.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$78.59
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$89.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$89.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$89.36
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$87.32
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$89.36
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Cigna Commercial |
$69.40
|
| Rate for Payer: Cigna Medicare Advantage |
$64.64
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$71.44
|
| Rate for Payer: Home State Health Plan Exchange |
$64.64
|
| Rate for Payer: Humana Medicare |
$85.05
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$85.05
|
| Rate for Payer: Provider Network of America Commercial |
$90.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$74.84
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$113.40
|
|
|
gemcitabine 2 gram/52.6 mL (38 mg/mL) solution 52.6 mL Vial
|
Facility
|
IP
|
$113.40
|
|
|
Service Code
|
NDC 00409018225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.05 |
| 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 |
$113.40
|
| Rate for Payer: Cash Price |
$113.40
|
| 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 |
$85.05
|
| Rate for Payer: Provider Network of America Commercial |
$90.72
|
|
|
GENDER RELATED PROCEDURES
|
Facility
|
IP
|
$30,414.83
|
|
|
Service Code
|
APR-DRG 8512
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$30,414.83 |
| 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 |
$30,414.83
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$30,414.83
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$30,414.83
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$30,414.83
|
|
|
GENDER RELATED PROCEDURES
|
Facility
|
IP
|
$116,422.83
|
|
|
Service Code
|
APR-DRG 8514
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$116,422.83 |
| 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 |
$116,422.83
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$116,422.83
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$116,422.83
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$116,422.83
|
|
|
GENDER RELATED PROCEDURES
|
Facility
|
IP
|
$116,422.83
|
|
|
Service Code
|
APR-DRG 8513
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$116,422.83 |
| 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 |
$116,422.83
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$116,422.83
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$116,422.83
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$116,422.83
|
|
|
GENDER RELATED PROCEDURES
|
Facility
|
IP
|
$21,082.73
|
|
|
Service Code
|
APR-DRG 8511
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$21,082.73 |
| 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 |
$21,082.73
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$21,082.73
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$21,082.73
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$21,082.73
|
|
|
GENETIC DISORDERS
|
Facility
|
IP
|
$14,117.41
|
|
|
Service Code
|
APR-DRG 4282
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$14,117.41 |
| 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 |
$14,117.41
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$14,117.41
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$14,117.41
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$14,117.41
|
|
|
GENETIC DISORDERS
|
Facility
|
IP
|
$30,751.35
|
|
|
Service Code
|
APR-DRG 4283
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$30,751.35 |
| 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 |
$30,751.35
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$30,751.35
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$30,751.35
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$30,751.35
|
|
|
GENETIC DISORDERS
|
Facility
|
IP
|
$52,153.97
|
|
|
Service Code
|
APR-DRG 4284
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$52,153.97 |
| 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 |
$52,153.97
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$52,153.97
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$52,153.97
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$52,153.97
|
|
|
GENETIC DISORDERS
|
Facility
|
IP
|
$7,521.89
|
|
|
Service Code
|
APR-DRG 4281
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$7,521.89 |
| 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 |
$7,521.89
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$7,521.89
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$7,521.89
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$7,521.89
|
|
|
gentamicin 0.1 % ointment 15 g Tube
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
NDC 00713068215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.50 |
| 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 |
$158.00
|
| Rate for Payer: Cash Price |
$158.00
|
| 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 |
$118.50
|
| Rate for Payer: Provider Network of America Commercial |
$126.40
|
|
|
gentamicin 0.1 % ointment 15 g Tube
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
NDC 00713068215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.06 |
| Max. Negotiated Rate |
$158.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$111.39
|
| Rate for Payer: Aetna Workers' Compensation |
$111.39
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$109.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$109.49
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$124.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$124.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$124.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$121.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$124.50
|
| Rate for Payer: Cash Price |
$158.00
|
| Rate for Payer: Cigna Commercial |
$96.70
|
| Rate for Payer: Cigna Medicare Advantage |
$90.06
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$99.54
|
| Rate for Payer: Home State Health Plan Exchange |
$90.06
|
| Rate for Payer: Humana Medicare |
$118.50
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$118.50
|
| Rate for Payer: Provider Network of America Commercial |
$126.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$104.28
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$158.00
|
|
|
gentamicin 40 mg/mL solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J1580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$24.68
|
| Rate for Payer: Aetna Workers' Compensation |
$24.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$26.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$27.58
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Commercial |
$21.42
|
| Rate for Payer: Cigna Medicare Advantage |
$19.95
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$22.05
|
| Rate for Payer: Home State Health Plan Exchange |
$19.95
|
| Rate for Payer: Humana Medicare |
$26.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Provider Network of America Commercial |
$28.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.10
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$35.00
|
|
|
gentamicin 40 mg/mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J1580
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
gentamicin 40 mg/mL solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 63323001001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$24.68
|
| Rate for Payer: Aetna Workers' Compensation |
$24.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$26.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$27.58
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Commercial |
$21.42
|
| Rate for Payer: Cigna Medicare Advantage |
$19.95
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$22.05
|
| Rate for Payer: Home State Health Plan Exchange |
$19.95
|
| Rate for Payer: Humana Medicare |
$26.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Provider Network of America Commercial |
$28.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.10
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$35.00
|
|
|
gentamicin 40 mg/mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 63323001001
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
gentamicin PF 20 mg/2 mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J1580
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
gentamicin PF 20 mg/2 mL solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J1580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$24.68
|
| Rate for Payer: Aetna Workers' Compensation |
$24.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$26.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$27.58
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Commercial |
$21.42
|
| Rate for Payer: Cigna Medicare Advantage |
$19.95
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$22.05
|
| Rate for Payer: Home State Health Plan Exchange |
$19.95
|
| Rate for Payer: Humana Medicare |
$26.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Provider Network of America Commercial |
$28.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.10
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$35.00
|
|
|
gentamicin PF 20 mg/2 mL solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 63323017301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$24.68
|
| Rate for Payer: Aetna Workers' Compensation |
$24.68
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$27.58
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$26.95
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$27.58
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Commercial |
$21.42
|
| Rate for Payer: Cigna Medicare Advantage |
$19.95
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$22.05
|
| Rate for Payer: Home State Health Plan Exchange |
$19.95
|
| Rate for Payer: Humana Medicare |
$26.25
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Provider Network of America Commercial |
$28.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$23.10
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$35.00
|
|
|
gentamicin PF 20 mg/2 mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 63323017301
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
gentian violet 1 % solution 59 mL Bottle
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00395100392
|
|
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
|
|
|
gentian violet 1 % solution 59 mL Bottle
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00395100392
|
|
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
|
|
