Ray County Hospital

All Charges

Charge

Type

Setting

Price

SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$31,970.79

Service Code	APR-DRG 3613
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$31,970.79
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	$31,970.79
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$31,970.79
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$31,970.79
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$31,970.79

SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$59,732.25

Service Code	APR-DRG 3614
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$59,732.25
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	$59,732.25
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$59,732.25
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$59,732.25
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$59,732.25

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$16,315.58

Service Code	MSDRG 574
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$16,315.58
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	$16,315.58

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$30,791.58

Service Code	MSDRG 573
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$30,791.58
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	$30,791.58

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$7,677.92

Service Code	MSDRG 575
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$7,677.92
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	$7,677.92

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$8,431.33

Service Code	MSDRG 623
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$8,431.33
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: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Humana Medicare	$8,431.33

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$16,728.24

Service Code	MSDRG 622
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$16,728.24
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	$16,728.24

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$6,053.00

Service Code	MSDRG 624
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	$5,883.93

SKIN GRAFTS FOR INJURIES WITH CC/MCC

Facility

$17,263.57

Service Code	MSDRG 904
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$17,263.57
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	$17,263.57

SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC

Facility

$6,729.46

Service Code	MSDRG 905
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$6,729.46
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	$6,729.46

Skin Sub Graft T/a/L Add 100 Sq Cm

Facility

$525.00

Service Code	CPT 15274
Hospital Charge Code	Px07611527401
Hospital Revenue Code	761
Min. Negotiated Rate	$393.75
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	$525.00
Rate for Payer: Cash Price	$525.00
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	$393.75
Rate for Payer: Provider Network of America Commercial	$420.00

Skin Sub Graft T/a/L Add 100 Sq Cm

Facility

$525.00

Service Code	CPT 15274
Hospital Charge Code	Px07611527401
Hospital Revenue Code	761
Min. Negotiated Rate	$299.25
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$370.12
Rate for Payer: Aetna Workers' Compensation	$370.12
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$363.82
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$363.82
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$413.70
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$413.70
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$413.70
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$404.25
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$413.70
Rate for Payer: Cash Price	$525.00
Rate for Payer: Cigna Commercial	$321.30
Rate for Payer: Cigna Medicare Advantage	$299.25
Rate for Payer: Harmony Health CHIP/Medicaid	$330.75
Rate for Payer: Home State Health Plan Exchange	$299.25
Rate for Payer: Humana Medicare	$393.75
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$393.75
Rate for Payer: Provider Network of America Commercial	$420.00
Rate for Payer: UnitedHealthcare Commercial	$346.50
Rate for Payer: UnitedHealthcare Individual Exchange	$525.00

Skin Sub Graft T/a/L Add 25 Sq Cm

Facility

$525.00

Service Code	CPT 15272
Hospital Charge Code	Px07611527201
Hospital Revenue Code	761
Min. Negotiated Rate	$299.25
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$370.12
Rate for Payer: Aetna Workers' Compensation	$370.12
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$363.82
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$363.82
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$413.70
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$413.70
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$413.70
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$404.25
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$413.70
Rate for Payer: Cash Price	$525.00
Rate for Payer: Cigna Commercial	$321.30
Rate for Payer: Cigna Medicare Advantage	$299.25
Rate for Payer: Harmony Health CHIP/Medicaid	$330.75
Rate for Payer: Home State Health Plan Exchange	$299.25
Rate for Payer: Humana Medicare	$393.75
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$393.75
Rate for Payer: Provider Network of America Commercial	$420.00
Rate for Payer: UnitedHealthcare Commercial	$346.50
Rate for Payer: UnitedHealthcare Individual Exchange	$525.00

Skin Sub Graft T/a/L Add 25 Sq Cm

Facility

$525.00

Service Code	CPT 15272
Hospital Charge Code	Px07611527201
Hospital Revenue Code	761
Min. Negotiated Rate	$393.75
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	$525.00
Rate for Payer: Cash Price	$525.00
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	$393.75
Rate for Payer: Provider Network of America Commercial	$420.00

Skin Sub Graft T/a/L Init 100 Sq Cm

Facility

$8,212.40

Service Code	CPT 15273
Hospital Charge Code	Px07611527301
Hospital Revenue Code	761
Min. Negotiated Rate	$1,960.38
Max. Negotiated Rate	$8,212.40
Rate for Payer: Aetna Commercial/Medicare Advantage	$5,789.74
Rate for Payer: Aetna Workers' Compensation	$5,789.74
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Advantage (HMO)	$5,691.19
Rate for Payer: Blue Cross Blue Shield of Kansas City Blue Care (HMO)	$5,691.19
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network	$6,471.37
Rate for Payer: Blue Cross Blue Shield of Kansas City Freedom Network Select	$6,471.37
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care	$6,471.37
Rate for Payer: Blue Cross Blue Shield of Kansas City Preferred Care Blue Risk (PPO)	$6,323.55
Rate for Payer: Blue Cross Blue Shield of Kansas City Traditional	$6,471.37
Rate for Payer: Cash Price	$8,212.40
Rate for Payer: Cash Price	$8,212.40
Rate for Payer: Cigna Commercial	$5,025.99
Rate for Payer: Cigna Medicare Advantage	$4,681.07
Rate for Payer: Family Health Partners Medicaid	$2,603.92
Rate for Payer: Harmony Health CHIP/Medicaid	$5,173.81
Rate for Payer: Healthy Blue Medicaid	$2,812.23
Rate for Payer: Home State Health Plan Exchange	$4,681.07
Rate for Payer: Home State Health Plan Medicaid	$2,603.92
Rate for Payer: Humana Medicare	$6,159.30
Rate for Payer: Mercy CarePlus Medicaid	$2,603.92
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$6,159.30
Rate for Payer: Provider Network of America Commercial	$6,569.92
Rate for Payer: UnitedHealthcare Commercial	$5,420.18
Rate for Payer: UnitedHealthcare Individual Exchange	$8,212.40
Rate for Payer: UnitedHealthcare Medicaid	$1,960.38

Skin Sub Graft T/a/L Init 100 Sq Cm

Facility

$8,212.40

Service Code	CPT 15273
Hospital Charge Code	Px07611527301
Hospital Revenue Code	761
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$6,569.92
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	$8,212.40
Rate for Payer: Cash Price	$8,212.40
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	$6,159.30
Rate for Payer: Provider Network of America Commercial	$6,569.92

SKIN ULCERS

Facility

$20,946.83

Service Code	APR-DRG 3804
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$20,946.83
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	$20,946.83
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$20,946.83
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$20,946.83
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$20,946.83

SKIN ULCERS

Facility

$7,796.47

Service Code	APR-DRG 3802
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$7,796.47
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	$7,796.47
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$7,796.47
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$7,796.47
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$7,796.47

SKIN ULCERS

Facility

$12,076.07

Service Code	APR-DRG 3803
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$12,076.07
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	$12,076.07
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$12,076.07
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$12,076.07
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$12,076.07

SKIN ULCERS

Facility

$6,053.00

Service Code	APR-DRG 3801
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	$5,544.34
Rate for Payer: Harmony Health CHIP/Medicaid	$1,826.00
Rate for Payer: Healthy Blue Medicaid	$5,544.34
Rate for Payer: Home State Health Plan Exchange	$6,053.00
Rate for Payer: Home State Health Plan Medicaid	$5,544.34
Rate for Payer: Humana Medicare	$1,185.00
Rate for Payer: Mercy CarePlus Medicaid	$5,544.34

SKIN ULCERS WITH CC

Facility

$6,053.00

Service Code	MSDRG 593
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	$5,575.61

SKIN ULCERS WITH MCC

Facility

$9,095.91

Service Code	MSDRG 592
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$9,095.91
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	$9,095.91

SKIN ULCERS WITHOUT CC/MCC

Facility

$6,053.00

Service Code	MSDRG 594
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	$4,073.96

Sleep Std Airflow Hrt Rate&O2 Sat Effort Unatt

Professional

Both

$4,917.15

Service Code	CPT 95806
Hospital Charge Code	Px00000095806
Hospital Revenue Code	520
Min. Negotiated Rate	$116.72
Max. Negotiated Rate	$116.72
Rate for Payer: Cash Price	$4,917.15
Rate for Payer: Oscar Health EPO/HMO/POS/PPO	$116.72

Slp Stdy Unatnd W/Hrt Rate/O2 Sat/Resp/Slp Time

Facility

$413.70

Service Code	CPT 95800
Hospital Charge Code	Px07409580001
Hospital Revenue Code	740
Min. Negotiated Rate	$310.27
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	$413.70
Rate for Payer: Cash Price	$413.70
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	$310.27
Rate for Payer: Provider Network of America Commercial	$330.96

Know your out-of-pocket cost for care.

All Charges