Ray County Hospital

All Charges

Charge

Type

Setting

Price

SICKLE CELL ANEMIA CRISIS

Facility

$6,149.90

Service Code	APR-DRG 6621
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$6,149.90
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	$6,149.90
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$6,149.90
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$6,149.90
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$6,149.90

SICKLE CELL ANEMIA CRISIS

Facility

$8,508.35

Service Code	APR-DRG 6622
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$8,508.35
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	$8,508.35
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$8,508.35
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$8,508.35
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$8,508.35

SICKLE CELL ANEMIA CRISIS

Facility

$25,762.65

Service Code	APR-DRG 6624
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$25,762.65
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	$25,762.65
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$25,762.65
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$25,762.65
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$25,762.65

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$6,212.46

Service Code	MSDRG 555
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$6,212.46
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	$6,212.46

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC

Facility

$6,053.00

Service Code	MSDRG 556
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	$3,903.82

SIGNS AND SYMPTOMS WITH MCC

Facility

$6,053.00

Service Code	MSDRG 947
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	$5,966.18

SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$6,053.00

Service Code	MSDRG 948
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	$3,762.35

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$17,489.13

Service Code	APR-DRG 8614
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$17,489.13
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	$17,489.13
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$17,489.13
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$17,489.13
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$17,489.13

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$6,053.00

Service Code	APR-DRG 8611
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	$5,587.79
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$5,587.79
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$5,587.79
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$5,587.79

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$10,811.33

Service Code	APR-DRG 8613
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$10,811.33
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	$10,811.33
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$10,811.33
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$10,811.33
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$10,811.33

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$7,256.55

Service Code	APR-DRG 8612
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$7,256.55
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$875.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$900.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Cigna Medicare Advantage	$6,053.00
Rate for Payer: Family Health Partners Medicaid	$7,256.55
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$7,256.55
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$7,256.55
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$7,256.55

silver nitrate applicators 75-25 % stick 100 Each Packet

Facility

$45.00

Service Code	NDC 12870000101
Hospital Revenue Code	637
Min. Negotiated Rate	$25.65
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$31.73
Rate for Payer: Aetna Workers' Compensation	$31.73
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$31.18
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$31.18
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$35.46
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$35.46
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$35.46
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$34.65
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$35.46
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna Commercial	$27.54
Rate for Payer: Cigna Medicare Advantage	$25.65
Rate for Payer: Harmony Health CHIP/Medicaid	$28.35
Rate for Payer: Home State Health Plan Exchange	$25.65
Rate for Payer: Humana Medicare	$33.75
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$33.75
Rate for Payer: Provider Network of America Commercial	$36.00
Rate for Payer: UnitedHealthcare Commercial	$29.70
Rate for Payer: UnitedHealthcare Individual Exchange	$45.00

silver nitrate applicators 75-25 % stick 100 Each Packet

Facility

$45.00

Service Code	NDC 12870000101
Hospital Revenue Code	637
Min. Negotiated Rate	$33.75
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	$45.00
Rate for Payer: Cash Price	$45.00
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	$33.75
Rate for Payer: Provider Network of America Commercial	$36.00

silver sulfADIAZINE 1 % cream 50 g Jar

Facility

$67.80

Service Code	NDC 67877012450
Hospital Revenue Code	637
Min. Negotiated Rate	$38.65
Max. Negotiated Rate	$67.80
Rate for Payer: Aetna Commercial/Medicare Advantage	$47.80
Rate for Payer: Aetna Workers' Compensation	$47.80
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$46.99
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$46.99
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$53.43
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$53.43
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$53.43
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$52.21
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$53.43
Rate for Payer: Cash Price	$67.80
Rate for Payer: Cigna Commercial	$41.49
Rate for Payer: Cigna Medicare Advantage	$38.65
Rate for Payer: Harmony Health CHIP/Medicaid	$42.71
Rate for Payer: Home State Health Plan Exchange	$38.65
Rate for Payer: Humana Medicare	$50.85
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$50.85
Rate for Payer: Provider Network of America Commercial	$54.24
Rate for Payer: UnitedHealthcare Commercial	$44.75
Rate for Payer: UnitedHealthcare Individual Exchange	$67.80

silver sulfADIAZINE 1 % cream 50 g Jar

Facility

$67.80

Service Code	NDC 67877012450
Hospital Revenue Code	637
Min. Negotiated Rate	$50.85
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	$67.80
Rate for Payer: Cash Price	$67.80
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	$50.85
Rate for Payer: Provider Network of America Commercial	$54.24

simethicone 80 mg tablet,chewable 1 Each BLIST PACK

Facility

$4.00

Service Code	NDC 77333081225
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

simethicone 80 mg tablet,chewable 1 Each BLIST PACK

Facility

$4.00

Service Code	NDC 77333081225
Hospital Revenue Code	637
Min. Negotiated Rate	$3.00
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	$4.00
Rate for Payer: Cash Price	$4.00
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	$3.00
Rate for Payer: Provider Network of America Commercial	$3.20

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$7,166.00

Service Code	MSDRG 194
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$7,166.00
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	$7,166.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$7,166.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$7,166.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$7,166.00
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	$3,787.73

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$6,177.68

Service Code	MSDRG 193
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$6,177.68
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	$6,177.68

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$6,053.00

Service Code	MSDRG 195
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	$4,475.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$4,475.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$4,475.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$950.00
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$4,475.00
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	$2,953.95

Simple Repair F/E/E/N/L/M 2.5cm/<

Professional

Both

$425.00

Service Code	CPT 12011
Hospital Charge Code	Px00000012011
Hospital Revenue Code	490
Min. Negotiated Rate	$65.72
Max. Negotiated Rate	$65.72
Rate for Payer: Cash Price	$425.00
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$65.72

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$26,341.62

Service Code	MSDRG 008
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$26,341.62
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	$26,341.62

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS

Facility

$31,147.84

Service Code	MSDRG 019
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$31,147.84
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: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$31,147.84

sincalide 5 mcg recon soln 1 Each Vial

Facility

$546.52

Service Code	HCPCS J2805
Hospital Revenue Code	250
Min. Negotiated Rate	$409.89
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	$546.52
Rate for Payer: Cash Price	$546.52
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	$409.89
Rate for Payer: Provider Network of America Commercial	$437.22

sincalide 5 mcg recon soln 1 Each Vial

Facility

$546.52

Service Code	HCPCS J2805
Hospital Revenue Code	250
Min. Negotiated Rate	$311.52
Max. Negotiated Rate	$546.52
Rate for Payer: Aetna Commercial/Medicare Advantage	$385.30
Rate for Payer: Aetna Workers' Compensation	$385.30
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$378.74
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$378.74
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$430.66
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$430.66
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$430.66
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$420.82
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$430.66
Rate for Payer: Cash Price	$546.52
Rate for Payer: Cigna Commercial	$334.47
Rate for Payer: Cigna Medicare Advantage	$311.52
Rate for Payer: Harmony Health CHIP/Medicaid	$344.31
Rate for Payer: Home State Health Plan Exchange	$311.52
Rate for Payer: Humana Medicare	$409.89
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$409.89
Rate for Payer: Provider Network of America Commercial	$437.22
Rate for Payer: UnitedHealthcare Commercial	$360.70
Rate for Payer: UnitedHealthcare Individual Exchange	$546.52

Know your out-of-pocket cost for care.

All Charges