|
NERVOUS SYSTEM MALIGNANCY
|
Facility
|
IP
|
$7,740.07
|
|
|
Service Code
|
APR-DRG 0411
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$7,740.07 |
| 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 |
$7,740.07
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$7,740.07
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$7,740.07
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$7,740.07
|
|
|
NERVOUS SYSTEM MALIGNANCY
|
Facility
|
IP
|
$22,929.92
|
|
|
Service Code
|
APR-DRG 0414
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$22,929.92 |
| 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 |
$22,929.92
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$22,929.92
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$22,929.92
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$22,929.92
|
|
|
NERVOUS SYSTEM MALIGNANCY
|
Facility
|
IP
|
$9,955.22
|
|
|
Service Code
|
APR-DRG 0412
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$9,955.22 |
| 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 |
$9,955.22
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Healthy Blue Medicaid |
$9,955.22
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Medicaid |
$9,955.22
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Mercy CarePlus Medicaid |
$9,955.22
|
|
|
NERVOUS SYSTEM NEOPLASMS WITH MCC
|
Facility
|
IP
|
$7,176.43
|
|
|
Service Code
|
MSDRG 054
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$7,176.43 |
| 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 |
$7,176.43
|
|
|
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 055
|
| 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 |
$4,792.12
|
|
|
NEUROLOGICAL EYE DISORDERS
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 123
|
| 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 |
$3,753.42
|
|
|
NEUROSES EXCEPT DEPRESSIVE
|
Facility
|
IP
|
$6,053.00
|
|
|
Service Code
|
MSDRG 882
|
| 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 |
$5,046.86
|
|
|
niCARdipine 25 mg/10 mL solution 10 mL Vial
|
Facility
|
IP
|
$76.45
|
|
|
Service Code
|
HCPCS J2404
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$57.34 |
| 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 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 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: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$950.00
|
| Rate for Payer: Cash Price |
$84.94
|
| Rate for Payer: Cash Price |
$84.94
|
| Rate for Payer: Cash Price |
$76.45
|
| Rate for Payer: Cash Price |
$76.45
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$63.70
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$57.34
|
| Rate for Payer: Provider Network of America Commercial |
$61.16
|
| Rate for Payer: Provider Network of America Commercial |
$67.95
|
|
|
niCARdipine 25 mg/10 mL solution 10 mL Vial
|
Facility
|
OP
|
$84.94
|
|
|
Service Code
|
NDC 55150018301
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$48.42 |
| Max. Negotiated Rate |
$84.94 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$59.88
|
| Rate for Payer: Aetna Workers' Compensation |
$59.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$58.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$58.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$66.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$66.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$66.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$65.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$66.93
|
| Rate for Payer: Cash Price |
$84.94
|
| Rate for Payer: Cigna Commercial |
$51.98
|
| Rate for Payer: Cigna Medicare Advantage |
$48.42
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$53.51
|
| Rate for Payer: Home State Health Plan Exchange |
$48.42
|
| Rate for Payer: Humana Medicare |
$63.70
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$63.70
|
| Rate for Payer: Provider Network of America Commercial |
$67.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$56.06
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$84.94
|
|
|
niCARdipine 25 mg/10 mL solution 10 mL Vial
|
Facility
|
IP
|
$76.45
|
|
|
Service Code
|
NDC 55150018302
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$57.34 |
| Max. Negotiated Rate |
$6,053.00 |
| Rate for Payer: Cash Price |
$76.45
|
| 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: Cash Price |
$76.45
|
| 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 |
$57.34
|
| Rate for Payer: Provider Network of America Commercial |
$61.16
|
|
|
niCARdipine 25 mg/10 mL solution 10 mL Vial
|
Facility
|
IP
|
$84.94
|
|
|
Service Code
|
NDC 55150018310
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$63.70 |
| 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 |
$84.94
|
| Rate for Payer: Cash Price |
$84.94
|
| 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 |
$63.70
|
| Rate for Payer: Provider Network of America Commercial |
$67.95
|
|
|
niCARdipine 25 mg/10 mL solution 10 mL Vial
|
Facility
|
OP
|
$76.45
|
|
|
Service Code
|
NDC 55150018302
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$43.58 |
| Max. Negotiated Rate |
$76.45 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$53.90
|
| Rate for Payer: Aetna Workers' Compensation |
$53.90
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$52.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$52.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$60.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$60.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$60.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$58.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$60.24
|
| Rate for Payer: Cash Price |
$76.45
|
| Rate for Payer: Cigna Commercial |
$46.79
|
| Rate for Payer: Cigna Medicare Advantage |
$43.58
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$48.16
|
| Rate for Payer: Home State Health Plan Exchange |
$43.58
|
| Rate for Payer: Humana Medicare |
$57.34
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$57.34
|
| Rate for Payer: Provider Network of America Commercial |
$61.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$50.46
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$76.45
|
|
|
niCARdipine 25 mg/10 mL solution 10 mL Vial
|
Facility
|
OP
|
$76.45
|
|
|
Service Code
|
HCPCS J2404
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$43.58 |
| Max. Negotiated Rate |
$76.45 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$53.90
|
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$59.88
|
| Rate for Payer: Aetna Workers' Compensation |
$53.90
|
| Rate for Payer: Aetna Workers' Compensation |
$59.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$52.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$58.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$52.98
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$58.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$66.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$60.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$66.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$60.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$60.24
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$66.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$58.87
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$65.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$66.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$60.24
|
| Rate for Payer: Cash Price |
$84.94
|
| Rate for Payer: Cash Price |
$76.45
|
| Rate for Payer: Cigna Commercial |
$46.79
|
| Rate for Payer: Cigna Commercial |
$51.98
|
| Rate for Payer: Cigna Medicare Advantage |
$43.58
|
| Rate for Payer: Cigna Medicare Advantage |
$48.42
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$48.16
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$53.51
|
| Rate for Payer: Home State Health Plan Exchange |
$43.58
|
| Rate for Payer: Home State Health Plan Exchange |
$48.42
|
| Rate for Payer: Humana Medicare |
$57.34
|
| Rate for Payer: Humana Medicare |
$63.70
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$57.34
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$63.70
|
| Rate for Payer: Provider Network of America Commercial |
$61.16
|
| Rate for Payer: Provider Network of America Commercial |
$67.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$50.46
|
| Rate for Payer: UnitedHealthcare Commercial |
$56.06
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$76.45
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$84.94
|
|
|
niCARdipine 25 mg/10 mL solution 10 mL Vial
|
Facility
|
IP
|
$84.94
|
|
|
Service Code
|
NDC 55150018301
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$63.70 |
| 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 |
$84.94
|
| Rate for Payer: Cash Price |
$84.94
|
| 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 |
$63.70
|
| Rate for Payer: Provider Network of America Commercial |
$67.95
|
|
|
niCARdipine 25 mg/10 mL solution 10 mL Vial
|
Facility
|
OP
|
$84.94
|
|
|
Service Code
|
NDC 55150018310
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$48.42 |
| Max. Negotiated Rate |
$84.94 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$59.88
|
| Rate for Payer: Aetna Workers' Compensation |
$59.88
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$58.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$58.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$66.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$66.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$66.93
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$65.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$66.93
|
| Rate for Payer: Cash Price |
$84.94
|
| Rate for Payer: Cigna Commercial |
$51.98
|
| Rate for Payer: Cigna Medicare Advantage |
$48.42
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$53.51
|
| Rate for Payer: Home State Health Plan Exchange |
$48.42
|
| Rate for Payer: Humana Medicare |
$63.70
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$63.70
|
| Rate for Payer: Provider Network of America Commercial |
$67.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$56.06
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$84.94
|
|
|
nicotine 14 mg/24 hr patch 24 hour 14 Each Box
|
Facility
|
OP
|
$7.42
|
|
|
Service Code
|
NDC 60505708900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5.23
|
| Rate for Payer: Aetna Workers' Compensation |
$5.23
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$5.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$5.85
|
| Rate for Payer: Cash Price |
$7.42
|
| Rate for Payer: Cigna Commercial |
$4.54
|
| Rate for Payer: Cigna Medicare Advantage |
$4.23
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$4.67
|
| Rate for Payer: Home State Health Plan Exchange |
$4.23
|
| Rate for Payer: Humana Medicare |
$5.57
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5.57
|
| Rate for Payer: Provider Network of America Commercial |
$5.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.90
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7.42
|
|
|
nicotine 14 mg/24 hr patch 24 hour 14 Each Box
|
Facility
|
IP
|
$7.42
|
|
|
Service Code
|
NDC 60505708900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.57 |
| 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 |
$7.42
|
| Rate for Payer: Cash Price |
$7.42
|
| 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 |
$5.57
|
| Rate for Payer: Provider Network of America Commercial |
$5.94
|
|
|
nicotine 14 mg/24 hr patch 24 hour 1 Each Packet
|
Facility
|
IP
|
$7.42
|
|
|
Service Code
|
NDC 60505706200
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.57 |
| 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 |
$7.42
|
| Rate for Payer: Cash Price |
$7.42
|
| 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 |
$5.57
|
| Rate for Payer: Provider Network of America Commercial |
$5.94
|
|
|
nicotine 14 mg/24 hr patch 24 hour 1 Each Packet
|
Facility
|
OP
|
$7.42
|
|
|
Service Code
|
NDC 60505706200
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5.23
|
| Rate for Payer: Aetna Workers' Compensation |
$5.23
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$5.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$5.85
|
| Rate for Payer: Cash Price |
$7.42
|
| Rate for Payer: Cigna Commercial |
$4.54
|
| Rate for Payer: Cigna Medicare Advantage |
$4.23
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$4.67
|
| Rate for Payer: Home State Health Plan Exchange |
$4.23
|
| Rate for Payer: Humana Medicare |
$5.57
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5.57
|
| Rate for Payer: Provider Network of America Commercial |
$5.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.90
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7.42
|
|
|
nicotine 21 mg/24 hr patch 24 hour 14 Each Box
|
Facility
|
IP
|
$7.42
|
|
|
Service Code
|
NDC 60505709000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.57 |
| 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 |
$7.42
|
| Rate for Payer: Cash Price |
$7.42
|
| 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 |
$5.57
|
| Rate for Payer: Provider Network of America Commercial |
$5.94
|
|
|
nicotine 21 mg/24 hr patch 24 hour 14 Each Box
|
Facility
|
OP
|
$7.42
|
|
|
Service Code
|
NDC 60505709000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5.23
|
| Rate for Payer: Aetna Workers' Compensation |
$5.23
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$5.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$5.85
|
| Rate for Payer: Cash Price |
$7.42
|
| Rate for Payer: Cigna Commercial |
$4.54
|
| Rate for Payer: Cigna Medicare Advantage |
$4.23
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$4.67
|
| Rate for Payer: Home State Health Plan Exchange |
$4.23
|
| Rate for Payer: Humana Medicare |
$5.57
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5.57
|
| Rate for Payer: Provider Network of America Commercial |
$5.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.90
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7.42
|
|
|
nicotine 21 mg/24 hr patch 24 hour 1 Each Packet
|
Facility
|
IP
|
$7.42
|
|
|
Service Code
|
NDC 60505706300
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.57 |
| 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 |
$7.42
|
| Rate for Payer: Cash Price |
$7.42
|
| 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 |
$5.57
|
| Rate for Payer: Provider Network of America Commercial |
$5.94
|
|
|
nicotine 21 mg/24 hr patch 24 hour 1 Each Packet
|
Facility
|
OP
|
$7.42
|
|
|
Service Code
|
NDC 60505706300
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5.23
|
| Rate for Payer: Aetna Workers' Compensation |
$5.23
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$5.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$5.85
|
| Rate for Payer: Cash Price |
$7.42
|
| Rate for Payer: Cigna Commercial |
$4.54
|
| Rate for Payer: Cigna Medicare Advantage |
$4.23
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$4.67
|
| Rate for Payer: Home State Health Plan Exchange |
$4.23
|
| Rate for Payer: Humana Medicare |
$5.57
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5.57
|
| Rate for Payer: Provider Network of America Commercial |
$5.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.90
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7.42
|
|
|
nicotine 7 mg/24 hr patch 24 hour 1 Each Packet
|
Facility
|
OP
|
$7.42
|
|
|
Service Code
|
NDC 60505706100
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$5.23
|
| Rate for Payer: Aetna Workers' Compensation |
$5.23
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$5.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$5.14
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$5.85
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$5.71
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$5.85
|
| Rate for Payer: Cash Price |
$7.42
|
| Rate for Payer: Cigna Commercial |
$4.54
|
| Rate for Payer: Cigna Medicare Advantage |
$4.23
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$4.67
|
| Rate for Payer: Home State Health Plan Exchange |
$4.23
|
| Rate for Payer: Humana Medicare |
$5.57
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$5.57
|
| Rate for Payer: Provider Network of America Commercial |
$5.94
|
| Rate for Payer: UnitedHealthcare Commercial |
$4.90
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$7.42
|
|
|
nicotine 7 mg/24 hr patch 24 hour 1 Each Packet
|
Facility
|
IP
|
$7.42
|
|
|
Service Code
|
NDC 60505706100
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.57 |
| 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 |
$7.42
|
| Rate for Payer: Cash Price |
$7.42
|
| 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 |
$5.57
|
| Rate for Payer: Provider Network of America Commercial |
$5.94
|
|
