Ray County Hospital

All Charges

Charge

Type

Setting

Price

OTHER SMALL AND LARGE BOWEL PROCEDURES

Facility

$12,206.42

Service Code	APR-DRG 2231
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$12,206.42
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$12,206.42
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$12,206.42
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$12,206.42
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$12,206.42

OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$9,084.32

Service Code	APR-DRG 2221
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$9,084.32
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: Family Health Partners Medicaid	$9,084.32
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$9,084.32
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$9,084.32
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$9,084.32

OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$23,059.35

Service Code	APR-DRG 2223
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$23,059.35
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: Family Health Partners Medicaid	$23,059.35
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$23,059.35
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$23,059.35
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$23,059.35

OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$41,518.30

Service Code	APR-DRG 2224
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$41,518.30
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	$41,518.30
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$41,518.30
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$41,518.30
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$41,518.30

OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES

Facility

$15,133.45

Service Code	APR-DRG 2222
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$15,133.45
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	$15,133.45
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$15,133.45
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$15,133.45
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$15,133.45

OTHER UPPER VASCULAR PROCEDURES

Facility

$18,229.67

Service Code	APR-DRG 1821
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$18,229.67
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	$18,229.67
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$18,229.67
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$18,229.67
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$18,229.67

OTHER UPPER VASCULAR PROCEDURES

Facility

$22,181.98

Service Code	APR-DRG 1822
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$22,181.98
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	$22,181.98
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$22,181.98
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$22,181.98
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$22,181.98

OTHER UPPER VASCULAR PROCEDURES

Facility

$43,239.75

Service Code	APR-DRG 1824
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$43,239.75
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	$43,239.75
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$43,239.75
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$43,239.75
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$43,239.75

OTHER UPPER VASCULAR PROCEDURES

Facility

$27,067.14

Service Code	APR-DRG 1823
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$27,067.14
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	$27,067.14
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$27,067.14
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$27,067.14
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$27,067.14

OTHER VASCULAR PROCEDURES WITH CC

Facility

$12,199.32

Service Code	MSDRG 253
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$12,199.32
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	$12,199.32

OTHER VASCULAR PROCEDURES WITH MCC

Facility

$16,395.01

Service Code	MSDRG 252
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$16,395.01
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	$16,395.01

OTHER VASCULAR PROCEDURES WITHOUT CC/MCC

Facility

$8,373.99

Service Code	MSDRG 254
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$8,373.99
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	$8,373.99

OTITIS MEDIA AND URI WITH MCC

Facility

$6,053.00

Service Code	MSDRG 152
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	$5,556.34

OTITIS MEDIA AND URI WITHOUT MCC

Facility

$6,053.00

Service Code	MSDRG 153
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 Freedom Network	$3,355.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$3,355.00
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	$3,469.54

Oxaliplatin

Facility

$25.86

Service Code	HCPCS J9263
Hospital Charge Code	Px0636J926301
Hospital Revenue Code	636
Min. Negotiated Rate	$19.39
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	$25.86
Rate for Payer: Cash Price	$25.86
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	$19.39
Rate for Payer: Provider Network of America Commercial	$20.69

Oxaliplatin

Facility

$25.86

Service Code	HCPCS J9263
Hospital Charge Code	Px0636J926301
Hospital Revenue Code	636
Min. Negotiated Rate	$14.74
Max. Negotiated Rate	$25.86
Rate for Payer: Aetna Commercial/Medicare Advantage	$18.23
Rate for Payer: Aetna Workers' Compensation	$18.23
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$17.92
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$17.92
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$20.38
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$20.38
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$20.38
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$19.91
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$20.38
Rate for Payer: Cash Price	$25.86
Rate for Payer: Cigna Commercial	$15.83
Rate for Payer: Cigna Medicare Advantage	$14.74
Rate for Payer: Harmony Health CHIP/Medicaid	$16.29
Rate for Payer: Home State Health Plan Exchange	$14.74
Rate for Payer: Humana Medicare	$19.39
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$19.39
Rate for Payer: Provider Network of America Commercial	$20.69
Rate for Payer: UnitedHealthcare Commercial	$17.07
Rate for Payer: UnitedHealthcare Individual Exchange	$25.86

oxaliplatin 100 mg/20 mL solution 20 mL Vial

Facility

$160.00

Service Code	HCPCS J9263
Hospital Revenue Code	250
Min. Negotiated Rate	$91.20
Max. Negotiated Rate	$160.00
Rate for Payer: Cash Price	$160.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$112.80
Rate for Payer: Aetna Workers' Compensation	$112.80
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$110.88
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$110.88
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$126.08
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$126.08
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$126.08
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$123.20
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$126.08
Rate for Payer: Cigna Commercial	$97.92
Rate for Payer: Cigna Medicare Advantage	$91.20
Rate for Payer: Harmony Health CHIP/Medicaid	$100.80
Rate for Payer: Home State Health Plan Exchange	$91.20
Rate for Payer: Humana Medicare	$120.00
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$120.00
Rate for Payer: Provider Network of America Commercial	$128.00
Rate for Payer: UnitedHealthcare Commercial	$105.60
Rate for Payer: UnitedHealthcare Individual Exchange	$160.00

oxaliplatin 100 mg/20 mL solution 20 mL Vial

Facility

$160.00

Service Code	HCPCS J9263
Hospital Revenue Code	250
Min. Negotiated Rate	$120.00
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	$160.00
Rate for Payer: Cash Price	$160.00
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	$120.00
Rate for Payer: Provider Network of America Commercial	$128.00

oxaliplatin 100 mg/20 mL solution 20 mL Vial

Facility

$160.00

Service Code	NDC 60505613207
Hospital Revenue Code	250
Min. Negotiated Rate	$91.20
Max. Negotiated Rate	$160.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$112.80
Rate for Payer: Aetna Workers' Compensation	$112.80
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$110.88
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$110.88
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$126.08
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$126.08
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$126.08
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$123.20
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$126.08
Rate for Payer: Cash Price	$160.00
Rate for Payer: Cigna Commercial	$97.92
Rate for Payer: Cigna Medicare Advantage	$91.20
Rate for Payer: Harmony Health CHIP/Medicaid	$100.80
Rate for Payer: Home State Health Plan Exchange	$91.20
Rate for Payer: Humana Medicare	$120.00
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$120.00
Rate for Payer: Provider Network of America Commercial	$128.00
Rate for Payer: UnitedHealthcare Commercial	$105.60
Rate for Payer: UnitedHealthcare Individual Exchange	$160.00

oxaliplatin 100 mg/20 mL solution 20 mL Vial

Facility

$160.00

Service Code	NDC 60505613207
Hospital Revenue Code	250
Min. Negotiated Rate	$120.00
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	$160.00
Rate for Payer: Cash Price	$160.00
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	$120.00
Rate for Payer: Provider Network of America Commercial	$128.00

oxaliplatin 50 mg/10 mL (5 mg/mL) solution 10 mL Vial

Facility

$80.00

Service Code	HCPCS J9263
Hospital Revenue Code	250
Min. Negotiated Rate	$45.60
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$56.40
Rate for Payer: Aetna Workers' Compensation	$56.40
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$55.44
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$55.44
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$63.04
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$63.04
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$63.04
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$61.60
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$63.04
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cigna Commercial	$48.96
Rate for Payer: Cigna Medicare Advantage	$45.60
Rate for Payer: Harmony Health CHIP/Medicaid	$50.40
Rate for Payer: Home State Health Plan Exchange	$45.60
Rate for Payer: Humana Medicare	$60.00
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$60.00
Rate for Payer: Provider Network of America Commercial	$64.00
Rate for Payer: UnitedHealthcare Commercial	$52.80
Rate for Payer: UnitedHealthcare Individual Exchange	$80.00

oxaliplatin 50 mg/10 mL (5 mg/mL) solution 10 mL Vial

Facility

$80.00

Service Code	HCPCS J9263
Hospital Revenue Code	250
Min. Negotiated Rate	$60.00
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	$80.00
Rate for Payer: Cash Price	$80.00
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	$60.00
Rate for Payer: Provider Network of America Commercial	$64.00

oxaliplatin 50 mg/10 mL (5 mg/mL) solution 10 mL Vial

Facility

$80.00

Service Code	NDC 60505613206
Hospital Revenue Code	250
Min. Negotiated Rate	$45.60
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$56.40
Rate for Payer: Aetna Workers' Compensation	$56.40
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$55.44
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$55.44
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$63.04
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$63.04
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$63.04
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$61.60
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$63.04
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cigna Commercial	$48.96
Rate for Payer: Cigna Medicare Advantage	$45.60
Rate for Payer: Harmony Health CHIP/Medicaid	$50.40
Rate for Payer: Home State Health Plan Exchange	$45.60
Rate for Payer: Humana Medicare	$60.00
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$60.00
Rate for Payer: Provider Network of America Commercial	$64.00
Rate for Payer: UnitedHealthcare Commercial	$52.80
Rate for Payer: UnitedHealthcare Individual Exchange	$80.00

oxaliplatin 50 mg/10 mL (5 mg/mL) solution 10 mL Vial

Facility

$80.00

Service Code	NDC 60505613206
Hospital Revenue Code	250
Min. Negotiated Rate	$60.00
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	$80.00
Rate for Payer: Cash Price	$80.00
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	$60.00
Rate for Payer: Provider Network of America Commercial	$64.00

OXcarbazepine 150 mg tablet 100 Each BLIST PACK

Facility

$4.00

Service Code	NDC 00904726261
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

Know your out-of-pocket cost for care.

All Charges