|
glycopyrrolate 0.2 mg/mL solution 2 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J1598
|
|
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
|
|
|
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
|
|
|
glycopyrrolate 0.2 mg/mL solution 2 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 43547054401
|
|
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
|
|
|
golimumab 12.5 mg/mL solution 4 mL Vial
|
Facility
|
OP
|
$7,996.76
|
|
|
Service Code
|
NDC 57894035001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,558.15 |
| Max. Negotiated Rate |
$7,996.76 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5,637.72
|
| Rate for Payer: Aetna Workers' Compensation |
$5,637.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5,541.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5,541.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$6,301.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$6,301.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$6,301.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$6,157.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$6,301.45
|
| Rate for Payer: Cash Price |
$7,996.76
|
| Rate for Payer: Cigna Commercial |
$4,894.02
|
| Rate for Payer: Cigna Medicare Advantage |
$4,558.15
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$5,037.96
|
| Rate for Payer: Home State Health Plan Exchange |
$4,558.15
|
| Rate for Payer: Humana Medicare |
$5,997.57
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5,997.57
|
| Rate for Payer: Provider Network of America Commercial |
$6,397.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,277.86
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7,996.76
|
|
|
golimumab 12.5 mg/mL solution 4 mL Vial
|
Facility
|
OP
|
$7,996.76
|
|
|
Service Code
|
HCPCS J1602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,558.15 |
| Max. Negotiated Rate |
$7,996.76 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5,637.72
|
| Rate for Payer: Aetna Workers' Compensation |
$5,637.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5,541.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5,541.75
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$6,301.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$6,301.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$6,301.45
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$6,157.51
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$6,301.45
|
| Rate for Payer: Cash Price |
$7,996.76
|
| Rate for Payer: Cigna Commercial |
$4,894.02
|
| Rate for Payer: Cigna Medicare Advantage |
$4,558.15
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$5,037.96
|
| Rate for Payer: Home State Health Plan Exchange |
$4,558.15
|
| Rate for Payer: Humana Medicare |
$5,997.57
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5,997.57
|
| Rate for Payer: Provider Network of America Commercial |
$6,397.41
|
| Rate for Payer: UnitedHealthcare Commercial |
$5,277.86
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7,996.76
|
|
|
golimumab 12.5 mg/mL solution 4 mL Vial
|
Facility
|
IP
|
$7,996.76
|
|
|
Service Code
|
HCPCS J1602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,397.41 |
| 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: Cash Price |
$7,996.76
|
| Rate for Payer: Cash Price |
$7,996.76
|
| 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 |
$5,997.57
|
| Rate for Payer: Provider Network of America Commercial |
$6,397.41
|
|
|
golimumab 12.5 mg/mL solution 4 mL Vial
|
Facility
|
IP
|
$7,996.76
|
|
|
Service Code
|
NDC 57894035001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$6,397.41 |
| 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: Cash Price |
$7,996.76
|
| Rate for Payer: Cash Price |
$7,996.76
|
| 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 |
$5,997.57
|
| Rate for Payer: Provider Network of America Commercial |
$6,397.41
|
|
|
Golimumab for iv use 1mg
|
Facility
|
IP
|
$6,136.96
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
Px0636J160201
|
|
Hospital Revenue Code
|
636
|
| 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 |
$6,136.96
|
| Rate for Payer: Cash Price |
$6,136.96
|
| 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 |
$4,602.72
|
| Rate for Payer: Provider Network of America Commercial |
$4,909.57
|
|
|
Golimumab for iv use 1mg
|
Facility
|
OP
|
$6,136.96
|
|
|
Service Code
|
HCPCS J1602
|
| Hospital Charge Code |
Px0636J160201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,498.07 |
| Max. Negotiated Rate |
$6,136.96 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$4,326.56
|
| Rate for Payer: Aetna Workers' Compensation |
$4,326.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$4,252.91
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$4,252.91
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$4,835.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$4,835.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$4,835.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$4,725.46
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$4,835.92
|
| Rate for Payer: Cash Price |
$6,136.96
|
| Rate for Payer: Cigna Commercial |
$3,755.82
|
| Rate for Payer: Cigna Medicare Advantage |
$3,498.07
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$3,866.28
|
| Rate for Payer: Home State Health Plan Exchange |
$3,498.07
|
| Rate for Payer: Humana Medicare |
$4,602.72
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$4,602.72
|
| Rate for Payer: Provider Network of America Commercial |
$4,909.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$4,050.39
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$6,136.96
|
|
|
Granisetron Hcl Injection
|
Facility
|
IP
|
$266.91
|
|
|
Service Code
|
CPT J1626
|
| Hospital Charge Code |
Px0636J162601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$200.18 |
| 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 |
$266.91
|
| Rate for Payer: Cash Price |
$266.91
|
| 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 |
$200.18
|
| Rate for Payer: Provider Network of America Commercial |
$213.53
|
|
|
Granisetron Hcl Injection
|
Facility
|
OP
|
$266.91
|
|
|
Service Code
|
CPT J1626
|
| Hospital Charge Code |
Px0636J162601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.14 |
| Max. Negotiated Rate |
$266.91 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$188.17
|
| Rate for Payer: Aetna Workers' Compensation |
$188.17
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$184.97
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$184.97
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$210.33
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$210.33
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$210.33
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$205.52
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$210.33
|
| Rate for Payer: Cash Price |
$266.91
|
| Rate for Payer: Cigna Commercial |
$163.35
|
| Rate for Payer: Cigna Medicare Advantage |
$152.14
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$168.15
|
| Rate for Payer: Home State Health Plan Exchange |
$152.14
|
| Rate for Payer: Humana Medicare |
$200.18
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$200.18
|
| Rate for Payer: Provider Network of America Commercial |
$213.53
|
| Rate for Payer: UnitedHealthcare Commercial |
$176.16
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$266.91
|
|
|
Group Psychotherapy
|
Facility
|
IP
|
$771.75
|
|
|
Service Code
|
CPT 90853
|
| Hospital Charge Code |
Px09159085301
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$578.81 |
| 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 |
$771.75
|
| Rate for Payer: Cash Price |
$771.75
|
| 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 |
$578.81
|
| Rate for Payer: Provider Network of America Commercial |
$617.40
|
|
|
Group Psychotherapy
|
Facility
|
OP
|
$771.75
|
|
|
Service Code
|
CPT 90853
|
| Hospital Charge Code |
Px09159085301
|
|
Hospital Revenue Code
|
915
|
| Min. Negotiated Rate |
$96.53 |
| Max. Negotiated Rate |
$771.75 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$544.08
|
| Rate for Payer: Aetna Workers' Compensation |
$544.08
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$534.82
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$534.82
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$608.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$608.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$608.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$594.25
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$608.14
|
| Rate for Payer: Cash Price |
$771.75
|
| Rate for Payer: Cash Price |
$771.75
|
| Rate for Payer: Cigna Commercial |
$472.31
|
| Rate for Payer: Cigna Medicare Advantage |
$439.90
|
| Rate for Payer: Family Health Partners Medicaid |
$128.21
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$486.20
|
| Rate for Payer: Healthy Blue Medicaid |
$138.47
|
| Rate for Payer: Home State Health Plan Exchange |
$439.90
|
| Rate for Payer: Home State Health Plan Medicaid |
$128.21
|
| Rate for Payer: Humana Medicare |
$578.81
|
| Rate for Payer: Mercy CarePlus Medicaid |
$128.21
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$578.81
|
| Rate for Payer: Provider Network of America Commercial |
$617.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$509.36
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$771.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$96.53
|
|
|
guaiFENesin 100 mg/5 mL liquid 15 mL Cup
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00121223215
|
|
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
|
|
|
guaiFENesin 100 mg/5 mL liquid 15 mL Cup
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00121223215
|
|
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
|
|
|
guaiFENesin 600 mg tablet extended release 12hr 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68084057201
|
|
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
|
|
|
guaiFENesin 600 mg tablet extended release 12hr 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904671839
|
|
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
|
|
|
guaiFENesin 600 mg tablet extended release 12hr 100 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904671839
|
|
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
|
|
|
guaiFENesin 600 mg tablet extended release 12hr 100 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68084057201
|
|
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
|
|
|
guaiFENesin 600 mg tablet extended release 12hr 1 Each BLIST PACK
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68084057211
|
|
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
|
|
|
guaiFENesin 600 mg tablet extended release 12hr 1 Each BLIST PACK
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68084057211
|
|
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
|
|
|
GYNECOLOGIC PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$10,228.88
|
|
|
Service Code
|
APR-DRG 5191
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$10,228.88 |
| 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 |
$10,228.88
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$10,228.88
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$10,228.88
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$10,228.88
|
|
|
GYNECOLOGIC PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$13,521.09
|
|
|
Service Code
|
APR-DRG 5192
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$13,521.09 |
| 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 |
$13,521.09
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$13,521.09
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$13,521.09
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$13,521.09
|
|
|
GYNECOLOGIC PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$23,528.08
|
|
|
Service Code
|
APR-DRG 5193
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$23,528.08 |
| 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 |
$23,528.08
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$23,528.08
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$23,528.08
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$23,528.08
|
|
|
GYNECOLOGIC PROCEDURES FOR LEIOMYOMA
|
Facility
|
IP
|
$37,009.42
|
|
|
Service Code
|
APR-DRG 5194
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$37,009.42 |
| 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 |
$37,009.42
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$37,009.42
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$37,009.42
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$37,009.42
|
|
