Ray County Hospital

All Charges

Charge

Type

Setting

Price

ampicillin-sulbactam 1.5 gram recon soln 1 Each Vial

Facility

$35.00

Service Code	HCPCS J0295
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

ampicillin-sulbactam 3 gram recon soln 1 Each Vial

Facility

$35.00

Service Code	NDC 00641611701
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

ampicillin-sulbactam 3 gram recon soln 1 Each Vial

Facility

$35.00

Service Code	NDC 72485041710
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

ampicillin-sulbactam 3 gram recon soln 1 Each Vial

Facility

$35.00

Service Code	NDC 72485041701
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

ampicillin-sulbactam 3 gram recon soln 1 Each Vial

Facility

$35.00

Service Code	NDC 00641611701
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

ampicillin-sulbactam 3 gram recon soln 1 Each Vial

Facility

$35.00

Service Code	HCPCS J0295
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

ampicillin-sulbactam 3 gram recon soln 1 Each Vial

Facility

$35.00

Service Code	NDC 72485041701
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

ampicillin-sulbactam 3 gram recon soln 1 Each Vial

Facility

$35.00

Service Code	HCPCS J0295
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

ampicillin-sulbactam 3 gram recon soln 1 Each Vial

Facility

$35.00

Service Code	NDC 72485041710
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

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC

Facility

$13,397.35

Service Code	MSDRG 240
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$13,397.35
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	$13,397.35

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC

Facility

$23,131.99

Service Code	MSDRG 239
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$23,131.99
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	$23,131.99

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC

Facility

$6,506.68

Service Code	MSDRG 241
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$6,506.68
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	$6,506.68

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$10,695.79

Service Code	MSDRG 475
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$10,695.79
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	$10,695.79

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$20,176.63

Service Code	MSDRG 474
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$20,176.63
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	$20,176.63

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$6,053.00

Service Code	MSDRG 476
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	$5,546.94

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$41,587.64

Service Code	APR-DRG 3054
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$41,587.64
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	$41,587.64
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$41,587.64
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$41,587.64
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$41,587.64

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$24,327.79

Service Code	APR-DRG 3053
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$24,327.79
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	$24,327.79
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$24,327.79
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$24,327.79
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$24,327.79

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$15,813.90

Service Code	APR-DRG 3052
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$15,813.90
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	$15,813.90
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$15,813.90
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$15,813.90
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$15,813.90

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$11,628.60

Service Code	APR-DRG 3051
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$11,628.60
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	$11,628.60
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$11,628.60
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$11,628.60
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$11,628.60

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$8,790.41

Service Code	MSDRG 617
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$8,790.41
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: 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	$8,790.41

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$16,390.78

Service Code	MSDRG 616
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$16,390.78
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	$16,390.78

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$6,666.01

Service Code	MSDRG 618
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$6,666.01
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	$6,666.01

Amputation Toe Interphalangeal Joint

Facility

$6,604.87

Service Code	CPT 28825
Hospital Charge Code	Px07612882501
Hospital Revenue Code	761
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	$6,604.87
Rate for Payer: Cash Price	$6,604.87
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	$4,953.65
Rate for Payer: Provider Network of America Commercial	$5,283.90

Amputation Toe Interphalangeal Joint

Facility

$6,604.87

Service Code	CPT 28825
Hospital Charge Code	Px07612882501
Hospital Revenue Code	761
Min. Negotiated Rate	$3,108.82
Max. Negotiated Rate	$6,604.87
Rate for Payer: Aetna Commercial/Medicare Advantage	$4,656.43
Rate for Payer: Aetna Workers' Compensation	$4,656.43
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$4,577.17
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$4,577.17
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$5,204.64
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$5,204.64
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$5,204.64
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$5,085.75
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$5,204.64
Rate for Payer: Cash Price	$6,604.87
Rate for Payer: Cash Price	$6,604.87
Rate for Payer: Cigna Commercial	$4,042.18
Rate for Payer: Cigna Medicare Advantage	$3,764.78
Rate for Payer: Family Health Partners Medicaid	$4,129.36
Rate for Payer: Harmony Health CHIP/Medicaid	$4,161.07
Rate for Payer: Healthy Blue Medicaid	$4,459.70
Rate for Payer: Home State Health Plan Exchange	$3,764.78
Rate for Payer: Home State Health Plan Medicaid	$4,129.36
Rate for Payer: Humana Medicare	$4,953.65
Rate for Payer: Mercy CarePlus Medicaid	$4,129.36
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$4,953.65
Rate for Payer: Provider Network of America Commercial	$5,283.90
Rate for Payer: UnitedHealthcare Commercial	$4,359.21
Rate for Payer: UnitedHealthcare Individual Exchange	$6,604.87
Rate for Payer: UnitedHealthcare Medicaid	$3,108.82

ANAL AND PERINEAL PROCEDURES

Facility

$9,166.61

Service Code	APR-DRG 2261
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$9,166.61
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	$9,166.61
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$9,166.61
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$9,166.61
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$9,166.61

Know your out-of-pocket cost for care.

All Charges