|
fentaNYL 12 mcg/hr patch 72 hour 1 Each Box
|
Facility
|
OP
|
$64.97
|
|
|
Service Code
|
NDC 00378911916
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.03 |
| Max. Negotiated Rate |
$64.97 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$45.80
|
| Rate for Payer: Aetna Workers' Compensation |
$45.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$45.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$45.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$51.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$51.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$51.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$50.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$51.20
|
| Rate for Payer: Cash Price |
$64.97
|
| Rate for Payer: Cigna Commercial |
$39.76
|
| Rate for Payer: Cigna Medicare Advantage |
$37.03
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$40.93
|
| Rate for Payer: Home State Health Plan Exchange |
$37.03
|
| Rate for Payer: Humana Medicare |
$48.73
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$48.73
|
| Rate for Payer: Provider Network of America Commercial |
$51.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$42.88
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$64.97
|
|
|
fentaNYL 12 mcg/hr patch 72 hour 1 Each Box
|
Facility
|
IP
|
$64.97
|
|
|
Service Code
|
NDC 00378911916
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.73 |
| 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 |
$64.97
|
| Rate for Payer: Cash Price |
$64.97
|
| 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 |
$48.73
|
| Rate for Payer: Provider Network of America Commercial |
$51.98
|
|
|
fentaNYL 12 mcg/hr patch 72 hour 1 Each Packet
|
Facility
|
OP
|
$64.97
|
|
|
Service Code
|
NDC 47781042311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.03 |
| Max. Negotiated Rate |
$64.97 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$45.80
|
| Rate for Payer: Aetna Workers' Compensation |
$45.80
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$45.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$45.02
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$51.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$51.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$51.20
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$50.03
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$51.20
|
| Rate for Payer: Cash Price |
$64.97
|
| Rate for Payer: Cigna Commercial |
$39.76
|
| Rate for Payer: Cigna Medicare Advantage |
$37.03
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$40.93
|
| Rate for Payer: Home State Health Plan Exchange |
$37.03
|
| Rate for Payer: Humana Medicare |
$48.73
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$48.73
|
| Rate for Payer: Provider Network of America Commercial |
$51.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$42.88
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$64.97
|
|
|
fentaNYL 12 mcg/hr patch 72 hour 1 Each Packet
|
Facility
|
IP
|
$64.97
|
|
|
Service Code
|
NDC 47781042311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.73 |
| 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 |
$64.97
|
| Rate for Payer: Cash Price |
$64.97
|
| 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 |
$48.73
|
| Rate for Payer: Provider Network of America Commercial |
$51.98
|
|
|
fentaNYL 25 mcg/hr patch 72 hour 1 Each Packet
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 50742055001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.40 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$14.10
|
| Rate for Payer: Aetna Workers' Compensation |
$14.10
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$13.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$13.86
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$15.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$15.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$15.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$15.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$15.76
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$12.24
|
| Rate for Payer: Cigna Medicare Advantage |
$11.40
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$12.60
|
| Rate for Payer: Home State Health Plan Exchange |
$11.40
|
| Rate for Payer: Humana Medicare |
$15.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$15.00
|
| Rate for Payer: Provider Network of America Commercial |
$16.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.20
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$20.00
|
|
|
fentaNYL 25 mcg/hr patch 72 hour 1 Each Packet
|
Facility
|
OP
|
$28.52
|
|
|
Service Code
|
NDC 47781042411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.26 |
| Max. Negotiated Rate |
$28.52 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$20.11
|
| Rate for Payer: Aetna Workers' Compensation |
$20.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$19.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$19.76
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$22.47
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$22.47
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$22.47
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$21.96
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$22.47
|
| Rate for Payer: Cash Price |
$28.52
|
| Rate for Payer: Cigna Commercial |
$17.45
|
| Rate for Payer: Cigna Medicare Advantage |
$16.26
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$17.97
|
| Rate for Payer: Home State Health Plan Exchange |
$16.26
|
| Rate for Payer: Humana Medicare |
$21.39
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$21.39
|
| Rate for Payer: Provider Network of America Commercial |
$22.82
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.82
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$28.52
|
|
|
fentaNYL 25 mcg/hr patch 72 hour 1 Each Packet
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 50742055001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.00 |
| 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 |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| 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 |
$15.00
|
| Rate for Payer: Provider Network of America Commercial |
$16.00
|
|
|
fentaNYL 25 mcg/hr patch 72 hour 1 Each Packet
|
Facility
|
IP
|
$28.52
|
|
|
Service Code
|
NDC 47781042411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.39 |
| 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 |
$28.52
|
| Rate for Payer: Cash Price |
$28.52
|
| 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 |
$21.39
|
| Rate for Payer: Provider Network of America Commercial |
$22.82
|
|
|
fentaNYL 50 mcg/hr patch 72 hour 1 Each Packet
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 50742055201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.96 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$19.74
|
| Rate for Payer: Aetna Workers' Compensation |
$19.74
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$19.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$19.40
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$22.06
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$22.06
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$22.06
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$21.56
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$22.06
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Cigna Commercial |
$17.14
|
| Rate for Payer: Cigna Medicare Advantage |
$15.96
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$17.64
|
| Rate for Payer: Home State Health Plan Exchange |
$15.96
|
| Rate for Payer: Humana Medicare |
$21.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$21.00
|
| Rate for Payer: Provider Network of America Commercial |
$22.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.48
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$28.00
|
|
|
fentaNYL 50 mcg/hr patch 72 hour 1 Each Packet
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 50742055201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.00 |
| 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 |
$28.00
|
| Rate for Payer: Cash Price |
$28.00
|
| 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 |
$21.00
|
| Rate for Payer: Provider Network of America Commercial |
$22.40
|
|
|
fentaNYL 50 mcg/hr patch 72 hour 5 Each Box
|
Facility
|
OP
|
$50.66
|
|
|
Service Code
|
NDC 00378912298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.88 |
| Max. Negotiated Rate |
$50.66 |
| Rate for Payer: Aetna Commercial/Medicare Advantage |
$35.72
|
| Rate for Payer: Aetna Workers' Compensation |
$35.72
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO) |
$35.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO) |
$35.11
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network |
$39.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select |
$39.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care |
$39.92
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO) |
$39.01
|
| Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional |
$39.92
|
| Rate for Payer: Cash Price |
$50.66
|
| Rate for Payer: Cigna Commercial |
$31.00
|
| Rate for Payer: Cigna Medicare Advantage |
$28.88
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$31.92
|
| Rate for Payer: Home State Health Plan Exchange |
$28.88
|
| Rate for Payer: Humana Medicare |
$37.99
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$37.99
|
| Rate for Payer: Provider Network of America Commercial |
$40.53
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.44
|
| Rate for Payer: UnitedHealthcare Individual Exchange |
$50.66
|
|
|
fentaNYL 50 mcg/hr patch 72 hour 5 Each Box
|
Facility
|
IP
|
$50.66
|
|
|
Service Code
|
NDC 00378912298
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.99 |
| 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 |
$50.66
|
| Rate for Payer: Cash Price |
$50.66
|
| 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 |
$37.99
|
| Rate for Payer: Provider Network of America Commercial |
$40.53
|
|
|
fentaNYL 50 mcg/mL solution 1 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 63323080611
|
|
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
|
|
|
fentaNYL 50 mcg/mL solution 1 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00641624701
|
|
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
|
|
|
fentaNYL 50 mcg/mL solution 1 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J3010
|
|
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
|
|
|
fentaNYL 50 mcg/mL solution 1 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J3010
|
|
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
|
|
|
fentaNYL 50 mcg/mL solution 1 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 63323080601
|
|
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
|
|
|
fentaNYL 50 mcg/mL solution 1 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 63323080601
|
|
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
|
|
|
fentaNYL 50 mcg/mL solution 1 mL Vial
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 63323080611
|
|
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
|
|
|
fentaNYL 50 mcg/mL solution 1 mL Vial
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00641624701
|
|
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
|
|
|
fentaNYL 50 mcg/mL solution 2 mL AMPUL
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00409909311
|
|
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
|
|
|
fentaNYL 50 mcg/mL solution 2 mL AMPUL
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 00409909311
|
|
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
|
|
|
fentaNYL 50 mcg/mL solution 2 mL AMPUL
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J3010
|
|
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
|
|
|
fentaNYL 50 mcg/mL solution 2 mL AMPUL
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS J3010
|
|
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
|
|
|
Fentanyl citrate injection
|
Facility
|
IP
|
$71.40
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
Px0636J301001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.55 |
| 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 |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Medicare Advantage |
$6,053.00
|
| Rate for Payer: Harmony Health CHIP/Medicaid |
$1,826.00
|
| Rate for Payer: Home State Health Plan Exchange |
$6,053.00
|
| Rate for Payer: Humana Medicare |
$1,185.00
|
| Rate for Payer: Oscar Health EPO/HMO/POS/PPO |
$53.55
|
| Rate for Payer: Provider Network of America Commercial |
$57.12
|
|
