Ray County Hospital

All Charges

Charge

Type

Setting

Price

midodrine 5 mg tablet 100 Each BLIST PACK

Facility

$4.00

Service Code	NDC 00904681861
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

midodrine 5 mg tablet 1 Each BLIST PACK

Facility

$4.00

Service Code	NDC 50268056211
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

midodrine 5 mg tablet 1 Each BLIST PACK

Facility

$4.00

Service Code	NDC 50268056211
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

midodrine 5 mg tablet 50 Each BLIST PACK

Facility

$4.00

Service Code	NDC 50268056215
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

midodrine 5 mg tablet 50 Each BLIST PACK

Facility

$4.00

Service Code	NDC 50268056215
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

MIGRAINE AND OTHER HEADACHES

Facility

$12,043.71

Service Code	APR-DRG 0543
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$12,043.71
Rate for Payer: Healthy Blue Medicaid	$12,043.71
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$12,043.71
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$12,043.71
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$12,043.71

MIGRAINE AND OTHER HEADACHES

Facility

$7,343.45

Service Code	APR-DRG 0541
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$7,343.45
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	$7,343.45
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$7,343.45
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$7,343.45
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$7,343.45

MIGRAINE AND OTHER HEADACHES

Facility

$19,352.03

Service Code	APR-DRG 0544
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$19,352.03
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	$19,352.03
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$19,352.03
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$19,352.03
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$19,352.03

MIGRAINE AND OTHER HEADACHES

Facility

$8,646.10

Service Code	APR-DRG 0542
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$8,646.10
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$8,646.10
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$8,646.10
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$8,646.10
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$8,646.10

MINOR BLADDER PROCEDURES WITH CC

Facility

$7,144.94

Service Code	MSDRG 663
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$7,144.94
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: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$7,144.94

MINOR BLADDER PROCEDURES WITH MCC

Facility

$14,389.05

Service Code	MSDRG 662
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$14,389.05
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: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$14,389.05

MINOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$6,053.00

Service Code	MSDRG 664
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: 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	$4,920.43

MINOR SKIN DISORDERS WITH MCC

Facility

$7,112.04

Service Code	MSDRG 606
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$7,112.04
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: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$7,112.04

MINOR SKIN DISORDERS WITHOUT MCC

Facility

$6,053.00

Service Code	MSDRG 607
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: 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	$4,260.08

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC

Facility

$7,072.09

Service Code	MSDRG 345
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$7,072.09
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: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$7,072.09

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC

Facility

$12,139.16

Service Code	MSDRG 344
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$12,139.16
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: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$12,139.16

MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC

Facility

$6,053.00

Service Code	MSDRG 346
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: 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	$5,575.14

mirabegron ER 25 mg tablet extended release 24 hr 30 Each Bottle

Facility

$61.37

Service Code	NDC 00469260130
Hospital Revenue Code	637
Min. Negotiated Rate	$46.03
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	$61.37
Rate for Payer: Cash Price	$61.37
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	$46.03
Rate for Payer: Provider Network of America Commercial	$49.10

mirabegron ER 25 mg tablet extended release 24 hr 30 Each Bottle

Facility

$61.37

Service Code	NDC 00469260130
Hospital Revenue Code	637
Min. Negotiated Rate	$34.98
Max. Negotiated Rate	$61.37
Rate for Payer: Aetna Commercial/Medicare Advantage	$43.27
Rate for Payer: Aetna Workers' Compensation	$43.27
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$42.53
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$42.53
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$48.36
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$48.36
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$48.36
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$47.25
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$48.36
Rate for Payer: Cash Price	$61.37
Rate for Payer: Cigna Commercial	$37.56
Rate for Payer: Cigna Medicare Advantage	$34.98
Rate for Payer: Harmony Health CHIP/Medicaid	$38.66
Rate for Payer: Home State Health Plan Exchange	$34.98
Rate for Payer: Humana Medicare	$46.03
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$46.03
Rate for Payer: Provider Network of America Commercial	$49.10
Rate for Payer: UnitedHealthcare Commercial	$40.50
Rate for Payer: UnitedHealthcare Individual Exchange	$61.37

Mirena, 52 Mg

Facility

$3,643.89

Service Code	HCPCS J7298
Hospital Charge Code	Px0636J729801
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	$3,643.89
Rate for Payer: Cash Price	$3,643.89
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	$2,732.92
Rate for Payer: Provider Network of America Commercial	$2,915.11

Mirena, 52 Mg

Facility

$3,643.89

Service Code	HCPCS J7298
Hospital Charge Code	Px0636J729801
Hospital Revenue Code	636
Min. Negotiated Rate	$2,077.02
Max. Negotiated Rate	$3,643.89
Rate for Payer: Aetna Commercial/Medicare Advantage	$2,568.94
Rate for Payer: Aetna Workers' Compensation	$2,568.94
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$2,525.22
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$2,525.22
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$2,871.39
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$2,871.39
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$2,871.39
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$2,805.80
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$2,871.39
Rate for Payer: Cash Price	$3,643.89
Rate for Payer: Cigna Commercial	$2,230.06
Rate for Payer: Cigna Medicare Advantage	$2,077.02
Rate for Payer: Harmony Health CHIP/Medicaid	$2,295.65
Rate for Payer: Home State Health Plan Exchange	$2,077.02
Rate for Payer: Humana Medicare	$2,732.92
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$2,732.92
Rate for Payer: Provider Network of America Commercial	$2,915.11
Rate for Payer: UnitedHealthcare Commercial	$2,404.97
Rate for Payer: UnitedHealthcare Individual Exchange	$3,643.89

mirtazapine 15 mg tablet 1 Each BLIST PACK

Facility

$4.00

Service Code	NDC 68084011911
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

mirtazapine 15 mg tablet 1 Each BLIST PACK

Facility

$4.00

Service Code	NDC 68084011911
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

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC

Facility

$6,277.32

Service Code	MSDRG 640
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$6,277.32
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: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$6,277.32

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC

Facility

$6,053.00

Service Code	MSDRG 641
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: 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	$3,657.54

Know your out-of-pocket cost for care.

All Charges