|
glimepiride 2 mg tablet 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50268035911
|
|
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
|
|
|
glimepiride 2 mg tablet 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50268035911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: UnitedHealthcare Commercial |
$2.64
|
| 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 Individual Exchange |
$4.00
|
|
|
glipiZIDE 5 mg tablet 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904663761
|
|
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
|
|
|
glipiZIDE 5 mg tablet 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904663761
|
|
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
|
|
|
glipiZIDE XL 5 mg tablet extended release 24hr 100 Each Bottle
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 59651078101
|
|
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
|
|
|
glipiZIDE XL 5 mg tablet extended release 24hr 100 Each Bottle
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 59651078101
|
|
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
|
|
|
glipiZIDE XL 5 mg tablet extended release 24hr 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68084011111
|
|
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
|
|
|
glipiZIDE XL 5 mg tablet extended release 24hr 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68084011111
|
|
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
|
|
|
glucagon 1 mg/mL recon soln 1 Each Vial
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
NDC 63323059403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$342.00 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: UnitedHealthcare Commercial |
$396.00
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$423.00
|
| Rate for Payer: Aetna Workers' Compensation |
$423.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$415.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$415.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$472.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$472.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$472.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$462.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$472.80
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$367.20
|
| Rate for Payer: Cigna Medicare Advantage |
$342.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$378.00
|
| Rate for Payer: Home State Health Plan Exchange |
$342.00
|
| Rate for Payer: Humana Medicare |
$450.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$450.00
|
| Rate for Payer: Provider Network of America Commercial |
$480.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$600.00
|
|
|
glucagon 1 mg/mL recon soln 1 Each Vial
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS J1611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$450.00 |
| 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 |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| 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 |
$450.00
|
| Rate for Payer: Provider Network of America Commercial |
$480.00
|
|
|
glucagon 1 mg/mL recon soln 1 Each Vial
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS J1611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$342.00 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$423.00
|
| Rate for Payer: Aetna Workers' Compensation |
$423.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$415.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$415.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$472.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$472.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$472.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$462.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$472.80
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$367.20
|
| Rate for Payer: Cigna Medicare Advantage |
$342.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$378.00
|
| Rate for Payer: Home State Health Plan Exchange |
$342.00
|
| Rate for Payer: Humana Medicare |
$450.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$450.00
|
| Rate for Payer: Provider Network of America Commercial |
$480.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$396.00
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$600.00
|
|
|
glucagon 1 mg/mL recon soln 1 Each Vial
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
NDC 63323059403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$450.00 |
| 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 |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| 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 |
$450.00
|
| Rate for Payer: Provider Network of America Commercial |
$480.00
|
|
|
glucagon 1 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$1,230.80
|
|
|
Service Code
|
NDC 00169706515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$701.56 |
| Max. Negotiated Rate |
$1,230.80 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$867.71
|
| Rate for Payer: Aetna Workers' Compensation |
$867.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$852.94
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$852.94
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$969.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$969.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$969.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$947.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$969.87
|
| Rate for Payer: Cash Price |
$1,230.80
|
| Rate for Payer: Cigna Commercial |
$753.25
|
| Rate for Payer: Cigna Medicare Advantage |
$701.56
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$775.40
|
| Rate for Payer: Home State Health Plan Exchange |
$701.56
|
| Rate for Payer: Humana Medicare |
$923.10
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$923.10
|
| Rate for Payer: Provider Network of America Commercial |
$984.64
|
| Rate for Payer: UnitedHealthcare Commercial |
$812.33
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,230.80
|
|
|
glucagon 1 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$1,230.80
|
|
|
Service Code
|
HCPCS J1610
|
|
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 |
$1,230.80
|
| Rate for Payer: Cash Price |
$1,230.80
|
| 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 |
$923.10
|
| Rate for Payer: Provider Network of America Commercial |
$984.64
|
|
|
glucagon 1 mg recon soln 1 Each Vial
|
Facility
|
OP
|
$1,230.80
|
|
|
Service Code
|
HCPCS J1610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$701.56 |
| Max. Negotiated Rate |
$1,230.80 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$867.71
|
| Rate for Payer: Aetna Workers' Compensation |
$867.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$852.94
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$852.94
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$969.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$969.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$969.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$947.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$969.87
|
| Rate for Payer: Cash Price |
$1,230.80
|
| Rate for Payer: Cigna Commercial |
$753.25
|
| Rate for Payer: Cigna Medicare Advantage |
$701.56
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$775.40
|
| Rate for Payer: Home State Health Plan Exchange |
$701.56
|
| Rate for Payer: Humana Medicare |
$923.10
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$923.10
|
| Rate for Payer: Provider Network of America Commercial |
$984.64
|
| Rate for Payer: UnitedHealthcare Commercial |
$812.33
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$1,230.80
|
|
|
glucagon 1 mg recon soln 1 Each Vial
|
Facility
|
IP
|
$1,230.80
|
|
|
Service Code
|
NDC 00169706515
|
|
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 |
$1,230.80
|
| Rate for Payer: Cash Price |
$1,230.80
|
| 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 |
$923.10
|
| Rate for Payer: Provider Network of America Commercial |
$984.64
|
|
|
Glucagon hydrochloride/1 mg
|
Facility
|
IP
|
$359.98
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
Px0636J161001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$269.99 |
| 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 |
$359.98
|
| Rate for Payer: Cash Price |
$359.98
|
| 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 |
$269.99
|
| Rate for Payer: Provider Network of America Commercial |
$287.98
|
|
|
Glucagon hydrochloride/1 mg
|
Facility
|
OP
|
$359.98
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
Px0636J161001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$205.19 |
| Max. Negotiated Rate |
$359.98 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$253.79
|
| Rate for Payer: Aetna Workers' Compensation |
$253.79
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$249.47
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$249.47
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$283.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$283.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$283.66
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$277.18
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$283.66
|
| Rate for Payer: Cash Price |
$359.98
|
| Rate for Payer: Cigna Commercial |
$220.31
|
| Rate for Payer: Cigna Medicare Advantage |
$205.19
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$226.79
|
| Rate for Payer: Home State Health Plan Exchange |
$205.19
|
| Rate for Payer: Humana Medicare |
$269.99
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$269.99
|
| Rate for Payer: Provider Network of America Commercial |
$287.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$237.59
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$359.98
|
|
|
Gluc Bld Gluc Mntr Dev Cleared Fda Spec Home Use
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
CPT 82962
|
| Hospital Charge Code |
Px03018296201
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.50 |
| 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 |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| 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 |
$31.50
|
| Rate for Payer: Provider Network of America Commercial |
$33.60
|
|
|
Gluc Bld Gluc Mntr Dev Cleared Fda Spec Home Use
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
CPT 82962
|
| Hospital Charge Code |
Px03018296201
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$33.60 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$29.61
|
| Rate for Payer: Aetna Workers' Compensation |
$29.61
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$29.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$29.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$33.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$33.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$33.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$32.34
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$33.10
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$22.01
|
| Rate for Payer: Cigna Medicare Advantage |
$23.94
|
| Rate for Payer: Family Health Partners Medicaid |
$4.13
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$26.46
|
| Rate for Payer: Healthy Blue Medicaid |
$4.46
|
| Rate for Payer: Home State Health Plan Exchange |
$23.94
|
| Rate for Payer: Home State Health Plan Medicaid |
$4.13
|
| Rate for Payer: Humana Medicare |
$31.50
|
| Rate for Payer: Mercy CarePlus Medicaid |
$4.13
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$31.50
|
| Rate for Payer: Provider Network of America Commercial |
$33.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$27.72
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$3.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.11
|
|
|
glucose 4 gram tablet,chewable 10 Each Tube
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 56151161011
|
|
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
|
|
|
glucose 4 gram tablet,chewable 10 Each Tube
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 80681010000
|
|
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
|
|
|
glucose 4 gram tablet,chewable 10 Each Tube
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 80681010000
|
|
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
|
|
|
glucose 4 gram tablet,chewable 10 Each Tube
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 56151161011
|
|
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
|
|
|
glycopyrrolate 0.2 mg/mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 43547054401
|
|
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
|
|
