Ray County Hospital

All Charges

Charge

Type

Setting

Price

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$6,546.63

Service Code	MSDRG 858
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$6,546.63
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	$6,546.63

POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE

Facility

$17,054.60

Service Code	APR-DRG 7112
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$17,054.60
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	$17,054.60
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$17,054.60
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$17,054.60
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$17,054.60

POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE

Facility

$11,848.64

Service Code	APR-DRG 7111
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$11,848.64
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	$11,848.64
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$11,848.64
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$11,848.64
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$11,848.64

POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE

Facility

$47,276.20

Service Code	APR-DRG 7114
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$47,276.20
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	$47,276.20
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$47,276.20
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$47,276.20
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$47,276.20

POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE

Facility

$26,341.40

Service Code	APR-DRG 7113
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$26,341.40
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	$26,341.40
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$26,341.40
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$26,341.40
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$26,341.40

POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS

Facility

$26,719.52

Service Code	APR-DRG 7214
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$26,719.52
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	$26,719.52
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$26,719.52
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$26,719.52
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$26,719.52

POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS

Facility

$15,299.86

Service Code	APR-DRG 7213
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$15,299.86
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	$15,299.86
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$15,299.86
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$15,299.86
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$15,299.86

POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS

Facility

$6,364.39

Service Code	APR-DRG 7211
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$6,364.39
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	$6,364.39
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$6,364.39
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$6,364.39
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$6,364.39

POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS

Facility

$9,221.15

Service Code	APR-DRG 7212
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$9,221.15
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	$9,221.15
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$9,221.15
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$9,221.15
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$9,221.15

POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES

Facility

$7,942.06

Service Code	MSDRG 769
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$7,942.06
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	$7,942.06

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES

Facility

$6,053.00

Service Code	MSDRG 776
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	$3,077.09

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE

Facility

$8,428.84

Service Code	APR-DRG 5613
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$8,428.84
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$8,428.84
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$8,428.84
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$8,428.84
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$8,428.84

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE

Facility

$6,053.00

Service Code	APR-DRG 5612
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: Family Health Partners Medicaid	$4,539.39
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$4,539.39
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$4,539.39
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$4,539.39

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE

Facility

$17,812.71

Service Code	APR-DRG 5614
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$17,812.71
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$17,812.71
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$17,812.71
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$17,812.71
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$17,812.71

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE

Facility

$6,053.00

Service Code	APR-DRG 5611
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: Family Health Partners Medicaid	$2,730.10
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$2,730.10
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$2,730.10
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$2,730.10

POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE

Facility

$6,053.00

Service Code	APR-DRG 5481
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: Family Health Partners Medicaid	$4,667.90
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$4,667.90
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$4,667.90
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$4,667.90

POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE

Facility

$11,569.43

Service Code	APR-DRG 5482
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$11,569.43
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: Family Health Partners Medicaid	$11,569.43
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$11,569.43
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$11,569.43
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$11,569.43

POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE

Facility

$34,584.41

Service Code	APR-DRG 5484
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$34,584.41
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: Family Health Partners Medicaid	$34,584.41
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$34,584.41
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$34,584.41
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$34,584.41

POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE

Facility

$18,600.40

Service Code	APR-DRG 5483
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$18,600.40
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	$18,600.40
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$18,600.40
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$18,600.40
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$18,600.40

Postpartum Care Only Separate Procedure

Facility

$535.50

Service Code	CPT 59430
Hospital Charge Code	Px05105943001
Hospital Revenue Code	510
Min. Negotiated Rate	$305.24
Max. Negotiated Rate	$535.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$377.53
Rate for Payer: Aetna Workers' Compensation	$377.53
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$371.10
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$371.10
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$421.97
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$421.97
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$421.97
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$412.33
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$421.97
Rate for Payer: Cash Price	$535.50
Rate for Payer: Cigna Medicare Advantage	$305.24
Rate for Payer: Harmony Health CHIP/Medicaid	$337.37
Rate for Payer: Home State Health Plan Exchange	$305.24
Rate for Payer: Humana Medicare	$401.62
Rate for Payer: Provider Network of America Commercial	$428.40
Rate for Payer: UnitedHealthcare Commercial	$353.43
Rate for Payer: UnitedHealthcare Individual Exchange	$535.50

Postpartum Care Only Separate Procedure

Facility

$535.50

Service Code	CPT 59430
Hospital Charge Code	Px05105943001
Hospital Revenue Code	510
Min. Negotiated Rate	$428.40
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	$535.50
Rate for Payer: Cash Price	$535.50
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: Provider Network of America Commercial	$428.40

potassium bicarb-citric acid 25 mEq tablet, effervescent 1 Each Packet

Facility

$5.04

Service Code	NDC 00245532689
Hospital Revenue Code	637
Min. Negotiated Rate	$2.87
Max. Negotiated Rate	$5.04
Rate for Payer: Aetna Commercial/Medicare Advantage	$3.55
Rate for Payer: Aetna Workers' Compensation	$3.55
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$3.49
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$3.49
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$3.97
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$3.97
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$3.97
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$3.88
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$3.97
Rate for Payer: Cash Price	$5.04
Rate for Payer: Cigna Commercial	$3.08
Rate for Payer: Cigna Medicare Advantage	$2.87
Rate for Payer: Harmony Health CHIP/Medicaid	$3.18
Rate for Payer: Home State Health Plan Exchange	$2.87
Rate for Payer: Humana Medicare	$3.78
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$3.78
Rate for Payer: Provider Network of America Commercial	$4.03
Rate for Payer: UnitedHealthcare Commercial	$3.33
Rate for Payer: UnitedHealthcare Individual Exchange	$5.04

potassium bicarb-citric acid 25 mEq tablet, effervescent 1 Each Packet

Facility

$5.04

Service Code	NDC 00245532689
Hospital Revenue Code	637
Min. Negotiated Rate	$3.78
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	$5.04
Rate for Payer: Cash Price	$5.04
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$3.78
Rate for Payer: Provider Network of America Commercial	$4.03

potassium chloride 10 mEq/100 mL piggyback 100 mL Bag

Facility

$65.00

Service Code	NDC 00338070948
Hospital Revenue Code	250
Min. Negotiated Rate	$37.05
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$45.83
Rate for Payer: Aetna Workers' Compensation	$45.83
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$45.05
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$45.05
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$51.22
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$51.22
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$51.22
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$50.05
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$51.22
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cigna Commercial	$39.78
Rate for Payer: Cigna Medicare Advantage	$37.05
Rate for Payer: Harmony Health CHIP/Medicaid	$40.95
Rate for Payer: Home State Health Plan Exchange	$37.05
Rate for Payer: Humana Medicare	$48.75
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$48.75
Rate for Payer: Provider Network of America Commercial	$52.00
Rate for Payer: UnitedHealthcare Commercial	$42.90
Rate for Payer: UnitedHealthcare Individual Exchange	$65.00

potassium chloride 10 mEq/100 mL piggyback 100 mL Bag

Facility

$65.00

Service Code	NDC 00338070948
Hospital Revenue Code	250
Min. Negotiated Rate	$48.75
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	$65.00
Rate for Payer: Cash Price	$65.00
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	$48.75
Rate for Payer: Provider Network of America Commercial	$52.00

Know your out-of-pocket cost for care.

All Charges